Provider Demographics
NPI:1396717104
Name:JOHNSON, KIMBERLY D (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:BOHLMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1081 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2448
Mailing Address - Country:US
Mailing Address - Phone:573-426-4455
Mailing Address - Fax:
Practice Address - Street 1:1081 E 18TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2448
Practice Address - Country:US
Practice Address - Phone:734-262-4075
Practice Address - Fax:573-426-6723
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006002908207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG85104Medicare UPIN