Provider Demographics
NPI:1558700054
Name:JOHNSON, KENDRICK O (DO)
Entity Type:Individual
Prefix:DR
First Name:KENDRICK
Middle Name:O
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 1:8514 W DEER VALLEY RD
Mailing Address - Street 2:STE 105
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382
Mailing Address - Country:US
Mailing Address - Phone:623-226-8825
Mailing Address - Fax:623-226-8835
Practice Address - Street 1:2000 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2443
Practice Address - Country:US
Practice Address - Phone:602-249-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6702207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine