1063407237 NPI number — NINA F JOHNSON MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063407237 NPI number — NINA F JOHNSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
NINA
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FUKUNAGA
Provider Other First Name:
NINA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063407237
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1847
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUSKEGON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49443-1847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-727-4444
Provider Business Mailing Address Fax Number:
231-672-4451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1440 E SHERMAN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUSKEGON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49444-1878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-672-2008
Provider Business Practice Location Address Fax Number:
231-672-2009
Provider Enumeration Date:
09/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  01046939 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: 4301053554 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200129810 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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