Provider Demographics
NPI:1972846293
Name:JOHNSON, KYLE J (DO)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 WARREN AVE STE 401
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-1430
Mailing Address - Country:US
Mailing Address - Phone:401-330-2480
Mailing Address - Fax:401-808-6329
Practice Address - Street 1:900 WARREN AVE STE 401
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-1430
Practice Address - Country:US
Practice Address - Phone:401-330-2480
Practice Address - Fax:401-808-6329
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO01222207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIDO01222OtherLICENSE