Provider Demographics
NPI:1184695710
Name:JOHNSON, KEITH B (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:B
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:941-480-9322
Practice Address - Street 1:1370 E VENICE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-9082
Practice Address - Country:US
Practice Address - Phone:941-480-0500
Practice Address - Fax:941-480-9322
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58404208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372134500Medicaid
FL203445431OtherTAX ID
FL372134500Medicaid
FL18523SMedicare PIN
FLK8802Medicare ID - Type Unspecified