Provider Demographics
NPI:1346321114
Name:KENNETH S JOHNSON, M.D., INC.
Entity Type:Organization
Organization Name:KENNETH S JOHNSON, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-407-2080
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43322207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A433223Medicaid
CA00A433223Medicaid