Provider Demographics
NPI:1194781153
Name:JOHNSON, JEFFREY (CRNA)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13950 BUNKERHILL RD
Mailing Address - Street 2:
Mailing Address - City:MUNITH
Mailing Address - State:MI
Mailing Address - Zip Code:49259-9732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30200 TELEGRAPH RD
Practice Address - Street 2:SUITE 220
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4502
Practice Address - Country:US
Practice Address - Phone:248-258-5058
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704127280207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIR67688Medicare UPIN
MIN47230047Medicare ID - Type UnspecifiedLOC 99
MIN78650030Medicare ID - Type UnspecifiedLOC 01