Basic Information
| Provider Information | |||||||||
| NPI: | 1558658872 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 598 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480990598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149918200 | ||||||||
| FaxNumber: | 3149918285 | ||||||||
| Practice Location | |||||||||
| Address1: | 1080 HARRINGTON ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480432901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864937500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2011 | ||||||||
| LastUpdateDate: | 08/12/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 4301099123 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1558658872 | 05 | MI | MEDICAID |