Provider Demographics
NPI:1023199882
Name:JOHNSON, KENNETH S (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4259
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-4259
Mailing Address - Country:US
Mailing Address - Phone:562-407-2080
Mailing Address - Fax:
Practice Address - Street 1:18685 MAIN ST # A
Practice Address - Street 2:SUITE 600
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1723
Practice Address - Country:US
Practice Address - Phone:562-407-2080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43322207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A433223Medicaid
CAWA43322IMedicare PIN