Provider Demographics
NPI:1679568174
Name:JOHNSON, ANDREA G (CSPOMM DO MB)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CSPOMM DO MB
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1150 E SHERMAN BLVD STE 2400
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1886
Mailing Address - Country:US
Mailing Address - Phone:231-672-6336
Mailing Address - Fax:231-672-6335
Practice Address - Street 1:2501 JOLLY RD
Practice Address - Street 2:SUITE 120
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3676
Practice Address - Country:US
Practice Address - Phone:517-381-0299
Practice Address - Fax:517-381-9950
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009343208D00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
F09765Medicare UPIN
MI5330181Medicare ID - Type Unspecified