Provider Demographics
NPI:1740220292
Name:JOHNSTON, KENNETH CAMERON (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CAMERON
Last Name:JOHNSTON
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 1:3077 W JEFFERSON ST STE 206
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5264
Mailing Address - Country:US
Mailing Address - Phone:815-744-2500
Mailing Address - Fax:815-744-3550
Practice Address - Street 1:3077 W JEFFERSON ST
Practice Address - Street 2:SUITE 206
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5264
Practice Address - Country:US
Practice Address - Phone:815-744-2500
Practice Address - Fax:815-744-3550
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36 44774207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
217790Medicare ID - Type Unspecified
D09854Medicare UPIN