Provider Demographics
NPI:1184721599
Name:JOHNSON, KEVIN D (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
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 1:2609 ELECTRIC AVE
Mailing Address - Street 2:STE. A
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6589
Mailing Address - Country:US
Mailing Address - Phone:810-982-1300
Mailing Address - Fax:810-982-9802
Practice Address - Street 1:2609 ELECTRIC AVE
Practice Address - Street 2:STE. A
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6589
Practice Address - Country:US
Practice Address - Phone:810-982-1300
Practice Address - Fax:810-982-9802
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054492207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1807401112OtherBCBSM
MI2923602Medicaid
MI3149682Medicaid
MI1807401112OtherBCBSM
F52696Medicare UPIN