Provider Demographics
NPI:1689673105
Name:JOHNSON, KAVIN J (MD)
Entity Type:Individual
Prefix:
First Name:KAVIN
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9029 HIWASSEE ST NW
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:TN
Mailing Address - Zip Code:37310-5305
Mailing Address - Country:US
Mailing Address - Phone:423-665-9026
Mailing Address - Fax:423-584-6747
Practice Address - Street 1:9029 HIWASSEE ST NW
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:TN
Practice Address - Zip Code:37310-5305
Practice Address - Country:US
Practice Address - Phone:423-665-9026
Practice Address - Fax:423-584-6747
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2014-11-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN21478207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNA15880Medicare UPIN