Provider Demographics
NPI:1174574172
Name:JOHNSON, MICHAEL KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KEITH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2616 JORDAN LN NW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35816-1014
Mailing Address - Country:US
Mailing Address - Phone:256-851-8433
Mailing Address - Fax:256-851-6080
Practice Address - Street 1:2616 JORDAN LN NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35816-1014
Practice Address - Country:US
Practice Address - Phone:256-851-8433
Practice Address - Fax:256-851-6080
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-14
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL20179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009943525Medicaid
ALG41166Medicare UPIN
AL51519473Medicare ID - Type UnspecifiedMEDICARE PROVIDER #