Provider Demographics
NPI:1669494175
Name:JOHNSON, RICHARD KEITH (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:KEITH
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 1:1023 MEDICAL CENTER PKWY STE 311
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-7740
Mailing Address - Country:US
Mailing Address - Phone:334-418-6652
Mailing Address - Fax:833-645-0184
Practice Address - Street 1:1023 MEDICAL CENTER PKWY STE 311
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-7740
Practice Address - Country:US
Practice Address - Phone:334-418-6652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006015220208600000X
MS19773208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203735600Medicaid
MO209433OtherBLUE SHIELD
MO752753OtherHEALTHLINK
MS03826375Medicaid
$$$$$$$$$OtherTRICARE
MS03826375Medicaid
MO209433OtherBLUE SHIELD
MO958595236Medicare PIN
$$$$$$$$$OtherTRICARE