Provider Demographics
NPI:1417335050
Name:JOHNSON, KEARY LEE (MD)
Entity Type:Individual
Prefix:
First Name:KEARY
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:M
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:P.O. BOX 43
Mailing Address - Street 2:ROUTE 10860
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-1166
Mailing Address - Fax:330-580-5513
Practice Address - Street 1:1324 5TH ST N
Practice Address - Street 2:
Practice Address - City:NEW ULM
Practice Address - State:MN
Practice Address - Zip Code:56073
Practice Address - Country:US
Practice Address - Phone:507-217-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-15
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.026963207V00000X
390200000X
MN65868207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty