Provider Demographics
NPI:1780720979
Name:JOHNSON, KENDRICK MILLARD (MD)
Entity type:Individual
Prefix:DR
First Name:KENDRICK
Middle Name:MILLARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1650 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3405
Mailing Address - Country:US
Mailing Address - Phone:916-983-7470
Mailing Address - Fax:916-983-7470
Practice Address - Street 1:1650 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3400
Practice Address - Country:US
Practice Address - Phone:916-983-7470
Practice Address - Fax:916-983-7540
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG083104207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG24482Medicare UPIN