Provider Demographics
NPI:1063095784
Name:JOHNSON, DONALD (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6029 SUMMERSET DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-7341
Mailing Address - Country:US
Mailing Address - Phone:313-587-4754
Mailing Address - Fax:
Practice Address - Street 1:3875 BAY RD STE 2N
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-2423
Practice Address - Country:US
Practice Address - Phone:248-652-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-30
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301512156207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program