Provider Demographics
NPI:1609880806
Name:JOHNSON, KEITH EWING (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:EWING
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 1:178 CLIZBE AVE
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-7520
Mailing Address - Country:US
Mailing Address - Phone:518-843-8745
Mailing Address - Fax:518-842-9633
Practice Address - Street 1:178 CLIZBE AVE
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-7520
Practice Address - Country:US
Practice Address - Phone:518-843-8745
Practice Address - Fax:518-842-9633
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0008872207L00000X
NY240532-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology