Provider Demographics
NPI:1811478688
Name:JOHNSON, BENJAMIN KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
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 1:102 HORSESHOE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-9128
Mailing Address - Country:US
Mailing Address - Phone:773-559-0612
Mailing Address - Fax:
Practice Address - Street 1:1140 W HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2238
Practice Address - Country:US
Practice Address - Phone:417-317-5318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018031276207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine