Provider Demographics
NPI:1750490405
Name:JOHNSON, KERRY WAYNE (MD)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:WAYNE
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 1:910 HWY 3 WEST
Mailing Address - Street 2:
Mailing Address - City:NORMANGEE
Mailing Address - State:TX
Mailing Address - Zip Code:77871
Mailing Address - Country:US
Mailing Address - Phone:936-396-2806
Mailing Address - Fax:936-396-9000
Practice Address - Street 1:910 HWY 3 WEST
Practice Address - Street 2:
Practice Address - City:NORMANGEE
Practice Address - State:TX
Practice Address - Zip Code:77871
Practice Address - Country:US
Practice Address - Phone:936-396-2806
Practice Address - Fax:936-396-9000
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8878207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0975666-01Medicaid
TX00B75CMedicare ID - Type Unspecified
E77016Medicare UPIN