Provider Demographics
NPI:1568449494
Name:JOHNSON, KEITH A (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
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 1:1450 TREAT BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1450 TREAT BLVD
Practice Address - Street 2:STE 160
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-2168
Practice Address - Country:US
Practice Address - Phone:925-296-9000
Practice Address - Fax:925-296-9071
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87266207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB45608Medicare UPIN
CA00G872660Medicare PIN