Healthcare Provider Details

I. General information

NPI: 1285854315
Provider Name (Legal Business Name): LANNY LEO JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4658 CHIPPEWA DR
OKEMOS MI
48864-2060
US

IV. Provider business mailing address

4658 CHIPPEWA DR
OKEMOS MI
48864-2060
US

V. Phone/Fax

Practice location:
  • Phone: 517-347-8130
  • Fax: 517-347-8130
Mailing address:
  • Phone: 517-347-8130
  • Fax: 517-347-8130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number4301024011
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: