Provider Demographics
NPI:1518929538
Name:JOHNSON, KENNETH H (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:H
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 HEALTH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-2907
Mailing Address - Country:US
Mailing Address - Phone:740-593-1660
Mailing Address - Fax:740-593-0179
Practice Address - Street 1:2 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2907
Practice Address - Country:US
Practice Address - Phone:740-593-1660
Practice Address - Fax:740-593-0179
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1437204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME212530099Medicaid
ME010211810001OtherTRICARE
MEG16868Medicare UPIN
ME212530099Medicaid
ME010211810001OtherTRICARE