Provider Demographics
NPI:1285653618
Name:JOHNSON, LARRY C (MD)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:C
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 1:1401 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3313
Mailing Address - Country:US
Mailing Address - Phone:859-655-6100
Mailing Address - Fax:859-655-6148
Practice Address - Street 1:120 PROGRESS WAY
Practice Address - Street 2:
Practice Address - City:OWENTON
Practice Address - State:KY
Practice Address - Zip Code:40359-6032
Practice Address - Country:US
Practice Address - Phone:844-655-6100
Practice Address - Fax:502-484-2102
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35775207Q00000X, 207P00000X
KY35575207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64051022Medicaid
KY64051022Medicaid
KYH61905Medicare UPIN