Provider Demographics
NPI:1578824751
Name:JOHNSON, KEONNA D'WYETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:KEONNA
Middle Name:D'WYETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3401 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-5103
Mailing Address - Country:US
Mailing Address - Phone:215-707-3133
Mailing Address - Fax:215-707-3945
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-3133
Practice Address - Fax:215-707-3945
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD474272208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery