Provider Demographics
NPI:1588628739
Name:JOHNSON, KENNETH B (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:B
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 1:9330 LBJ FWY STE 800
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-4310
Mailing Address - Country:US
Mailing Address - Phone:972-792-5700
Mailing Address - Fax:214-506-1107
Practice Address - Street 1:12720 HILLCREST RD STE 300
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2089
Practice Address - Country:US
Practice Address - Phone:214-814-1550
Practice Address - Fax:214-814-1350
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8608207RC0000X, 207UN0901X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103576803Medicaid
TX103576801Medicaid
TX8513N0Medicare PIN
TX8966K1Medicare PIN
TX103576803Medicaid