Provider Demographics
NPI:1932182201
Name:JOHNSON, KENNETH TRAVIS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:TRAVIS
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:2812 HIGHWAY 28 E
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-5715
Practice Address - Country:US
Practice Address - Phone:318-528-3355
Practice Address - Fax:318-528-3356
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2017-04-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA017148207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1356280Medicaid
LA538347YJBAMedicare PIN
LAB62705Medicare UPIN