Provider Demographics
NPI:1457642845
Name:JOHNSON COUNTY DERMATOLOGY P.A.
Entity Type:Organization
Organization Name:JOHNSON COUNTY DERMATOLOGY P.A.
Other - Org Name:JOHN L. PROFFITT, M.D., P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAN-MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KROH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-764-1125
Mailing Address - Street 1:153 W 151ST ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-5348
Mailing Address - Country:US
Mailing Address - Phone:913-764-1125
Mailing Address - Fax:913-764-1186
Practice Address - Street 1:153 W 151ST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-5348
Practice Address - Country:US
Practice Address - Phone:913-764-1125
Practice Address - Fax:913-764-1186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSDE7997OtherRAILROAD MEDICARE
KSM820000Medicare PIN