Provider Demographics
NPI:1417155953
Name:JOHNSON, STEPHEN KENNEDY (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:KENNEDY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-272-5395
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:10211 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2147
Practice Address - Country:US
Practice Address - Phone:502-339-0444
Practice Address - Fax:502-339-1717
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1376103TC0700X
390200000X
KY46857208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50079132OtherPASSPORT-NCMA
KY000000885933OtherANTHEM-NCMA
KY165151OtherSIHO-NCMA
KY7100215230Medicaid
KYK147070Medicare PIN