Provider Demographics
NPI:1457349508
Name:JOHNSON, KENNETH IAN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:IAN
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 1:14690 SPRING HILL DR STE 305
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-8102
Mailing Address - Country:US
Mailing Address - Phone:352-277-5348
Mailing Address - Fax:352-606-2857
Practice Address - Street 1:1700 SE HILLMOOR DR STE 501
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952
Practice Address - Country:US
Practice Address - Phone:772-212-7049
Practice Address - Fax:772-212-7059
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73635207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80193338OtherRAILROAD
FLME73635OtherVHN
FL578869751OtherTRICARE
FLBCBSOther35407
FLME73635OtherDCWO
FLME73635OtherUNITED BENEFITS
FL258874900Medicaid
FLME73635OtherDCWO
FL35407ZMedicare ID - Type Unspecified