Provider Demographics
NPI:1407226582
Name:JOHNSON, KEITH W (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KEITH
Other - Middle Name:W
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:450 BAYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-6907
Mailing Address - Country:US
Mailing Address - Phone:651-665-0413
Mailing Address - Fax:
Practice Address - Street 1:450 BAYVIEW DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-6907
Practice Address - Country:US
Practice Address - Phone:651-665-0413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN186242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology