Provider Demographics
NPI:1376659805
Name:J KEVIN JOHNSON MD PC
Entity Type:Organization
Organization Name:J KEVIN JOHNSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-542-3100
Mailing Address - Street 1:1600 NORTH GRAND
Mailing Address - Street 2:SUITE 520
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003
Mailing Address - Country:US
Mailing Address - Phone:719-542-3100
Mailing Address - Fax:719-542-3110
Practice Address - Street 1:1600 NORTH GRAND
Practice Address - Street 2:SUITE 520
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003
Practice Address - Country:US
Practice Address - Phone:719-542-3100
Practice Address - Fax:719-542-3100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01365246Medicaid
CODD7190OtherRAILROAD MEDICARE
CO=========OtherUNITED HEALTH BOTH
CO01365246Medicaid
CO=========OtherUNITED HEALTH BOTH