Healthcare Provider Details

I. General information

NPI: 1962760124
Provider Name (Legal Business Name): JACOB DANIEL JOHNSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 11/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15411 PARK VILLAGE BLVD
TAYLOR MI
48180-4886
US

IV. Provider business mailing address

15411 PARK VILLAGE BLVD
TAYLOR MI
48180-4886
US

V. Phone/Fax

Practice location:
  • Phone: 646-714-1984
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number5101020933
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5101020933
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: