Provider Demographics
NPI:1346246386
Name:JOHNSON, KELLY A (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6403 MALCOLM DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-3104
Mailing Address - Country:US
Mailing Address - Phone:214-914-2480
Mailing Address - Fax:
Practice Address - Street 1:6403 MALCOLM DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-3104
Practice Address - Country:US
Practice Address - Phone:214-914-2480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN8669208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2461803Medicaid
OH2461803Medicaid