Provider Demographics
NPI:1790122141
Name:JOHNSON, KENDRICK DEWAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENDRICK
Middle Name:DEWAYNE
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 1:1430 TULANE AVE # 8047
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2632
Mailing Address - Country:US
Mailing Address - Phone:504-988-3524
Mailing Address - Fax:504-988-7846
Practice Address - Street 1:1430 TULANE AVE # 8047
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2632
Practice Address - Country:US
Practice Address - Phone:504-988-3524
Practice Address - Fax:504-988-7846
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-24
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.063144207T00000X
LA330499207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery