Provider Demographics
NPI:1477908747
Name:JOHNSON, BENJAMIN KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:KEITH
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 1:627 S. EDWIN C. MOSES BLVD
Mailing Address - Street 2:EAST MEDICAL PLAZA, 1ST FLOOR
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417
Mailing Address - Country:US
Mailing Address - Phone:937-223-8840
Mailing Address - Fax:
Practice Address - Street 1:147 GW HART ST
Practice Address - Street 2:
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311
Practice Address - Country:US
Practice Address - Phone:940-676-6075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH57.0277872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program