Healthcare Provider Details

I. General information

NPI: 1497751929
Provider Name (Legal Business Name): JULIE K JOHNSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 6TH ST
TRAVERSE CITY MI
49684-2349
US

IV. Provider business mailing address

4624 N SPIDER LAKE RD
TRAVERSE CITY MI
49696-8440
US

V. Phone/Fax

Practice location:
  • Phone: 231-947-0673
  • Fax: 801-740-2847
Mailing address:
  • Phone: 231-947-0673
  • Fax: 801-740-2847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number5101011139
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier930018880
Identifier TypeOTHER
Identifier StateMI
Identifier IssuerRAILROAD MEDICARE
# 2
Identifier3064262
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer
# 3
IdentifierJJ011139
Identifier TypeOTHER
Identifier StateMI
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: