Provider Demographics
NPI:1467628792
Name:JOHNSON, KEITH EMERY (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:EMERY
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 1:1111 QUEWHIFFLE RD
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NC
Mailing Address - Zip Code:28315-5377
Mailing Address - Country:US
Mailing Address - Phone:910-281-5122
Mailing Address - Fax:
Practice Address - Street 1:1111 QUEWHIFFLE RD
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:NC
Practice Address - Zip Code:28315-5377
Practice Address - Country:US
Practice Address - Phone:910-281-5122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30178208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC82147Medicare UPIN