Provider Demographics
NPI:1912140674
Name:JOHNSON, KYLE R (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:402-559-6195
Mailing Address - Fax:
Practice Address - Street 1:EMILE 42ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-4455
Practice Address - Country:US
Practice Address - Phone:402-559-4081
Practice Address - Fax:402-559-7372
Is Sole Proprietor?:No
Enumeration Date:2009-04-10
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55266-020207L00000X
NE29237207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1912140674Medicaid