Provider Demographics
NPI:1982697645
Name:JOHNSON, LEONARD B (MD)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:B
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 1:43800 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1136
Mailing Address - Country:US
Mailing Address - Phone:313-343-7280
Mailing Address - Fax:313-343-7921
Practice Address - Street 1:19251 MACK AVE
Practice Address - Street 2:333
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2893
Practice Address - Country:US
Practice Address - Phone:313-343-7280
Practice Address - Fax:313-343-7921
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062126207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3499036Medicaid
G80276Medicare UPIN
MI3499036Medicaid