Provider Demographics
NPI:1093196719
Name:KEITH P, JOHNSON, M.D., PLLC
Entity Type:Organization
Organization Name:KEITH P, JOHNSON, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:P
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-841-3931
Mailing Address - Street 1:314 W 14TH ST
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-5002
Mailing Address - Country:US
Mailing Address - Phone:212-620-0159
Mailing Address - Fax:917-388-3379
Practice Address - Street 1:314 W 14TH ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-5002
Practice Address - Country:US
Practice Address - Phone:212-620-0159
Practice Address - Fax:917-388-3379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211734207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty