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General NPI Number Information
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NPI Number | 1972768232
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Entity Type | Individual
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Provider Name | DERICK MICHAEL JOHNSON D.O.
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Gender | Male
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Dates
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Enumeration Date | 07/25/2008
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Last Update Date | 07/23/2014
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Provider Practice Location Address
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Address Line | 3299 N WELLNESS DR BLDG C, #150
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City | HOLLAND
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State | MI
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Zip | 49424-7269
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Country | US
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Telephone | 616-738-3884
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Fax | 616-738-4432
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Provider Business Mailing Address
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Address Line | 3299 N WELLNESS DR BLDG C, #150
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City | HOLLAND
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State | MI
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Zip | 49424-7269
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Country | US
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Telephone | 616-738-3884
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Fax | 616-738-4432
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 58.001489
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 0102202412
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | L1206639
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License Number State | MI
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