Provider Demographics
NPI:1558369058
Name:JOHNSON, KEITH R (MD PA)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
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Mailing Address - Street 1:1300 MURCHISON
Mailing Address - Street 2:SUITE 312
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902
Mailing Address - Country:US
Mailing Address - Phone:915-217-1107
Mailing Address - Fax:915-217-1299
Practice Address - Street 1:1300 MURCHISON
Practice Address - Street 2:SUITE 312
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902
Practice Address - Country:US
Practice Address - Phone:915-217-1107
Practice Address - Fax:915-217-1299
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL4010174400000X, 207X00000X, 207XS0114X, 207XX0004X, 207XS0106X, 207XX0801X, 207XP3100X, 207XX0005X, 2086S0127X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No174400000XOther Service ProvidersSpecialist
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151853205Medicaid
TX8F20596OtherINDIVIDUAL PTAN
TX151853205Medicaid
TX6415440001Medicare NSC