Provider Demographics
NPI:1679685598
Name:JOHNSON, KEVIN M (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
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 1:608 NORTHWEST BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2174
Mailing Address - Country:US
Mailing Address - Phone:208-676-8346
Mailing Address - Fax:
Practice Address - Street 1:608 NORTHWEST BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2174
Practice Address - Country:US
Practice Address - Phone:208-676-8346
Practice Address - Fax:208-664-5345
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7963208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807104000Medicaid
ID807104000Medicaid
IDG05469Medicare UPIN