Provider Demographics
NPI:1790950897
Name:JOHNSON, KEVIN MAURICE (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MAURICE
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 1:2722 MERRILEE DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4420
Mailing Address - Country:US
Mailing Address - Phone:703-698-4483
Mailing Address - Fax:703-698-2176
Practice Address - Street 1:2722 MERRILEE DR
Practice Address - Street 2:SUITE 230
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4420
Practice Address - Country:US
Practice Address - Phone:703-698-4483
Practice Address - Fax:703-698-2176
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00880502085R0202X
VA01012450832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0109OtherCAREFIRST BCBS
VA282568OtherKAISER PERMANENTE
VA9592327OtherAETNA - PPO
VA0101245083OtherMEDICAL LICENSE
VA3848144OtherAETNA - HMO
VA0109OtherCAREFIRST BCBS
VA282568OtherKAISER PERMANENTE