Basic Information
| Provider Information | |||||||||
| NPI: | 1467682971 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30516 | ||||||||
| Address2: | DEPT#9516 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489097919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319350497 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1105 SIXTH STREET | ||||||||
| Address2: | SUITE#100 | ||||||||
| City: | 49684 TRAVERSE CITY, MI (GRAND TRAVERSE) | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319355000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2009 | ||||||||
| LastUpdateDate: | 05/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301094869 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.