Provider Demographics
NPI:1760750194
Name:JOHNSON, KENNETH CASPER (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CASPER
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 1:3915 SKYLINE RD
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-2746
Mailing Address - Country:US
Mailing Address - Phone:760-729-0350
Mailing Address - Fax:760-729-0350
Practice Address - Street 1:3915 SKYLINE RD
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2746
Practice Address - Country:US
Practice Address - Phone:760-729-0350
Practice Address - Fax:760-729-0350
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGFE20398207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology