Provider Demographics
NPI:1326280991
Name:JOHNSON, KEVIN ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANTHONY
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 1:3602 S LOYOLA DR APT 296
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-6429
Mailing Address - Country:US
Mailing Address - Phone:504-275-7264
Mailing Address - Fax:
Practice Address - Street 1:1400 HANCOCK BLVD
Practice Address - Street 2:#1208
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114
Practice Address - Country:US
Practice Address - Phone:386-252-2524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-29
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA205288207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty