Provider Demographics
NPI:1790729374
Name:JOHNSON, ROBERT KEYIRCE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KEYIRCE
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 1:401 W SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2815
Mailing Address - Country:US
Mailing Address - Phone:210-736-3126
Mailing Address - Fax:210-733-1953
Practice Address - Street 1:401 W SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2815
Practice Address - Country:US
Practice Address - Phone:210-736-3126
Practice Address - Fax:210-733-1953
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1687208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE80949Medicare UPIN