Provider Demographics
NPI:1952371874
Name:JOHNSON, KEVIN (MD PC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 822
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35056-0822
Mailing Address - Country:US
Mailing Address - Phone:256-734-9472
Mailing Address - Fax:256-734-9272
Practice Address - Street 1:1403 WALL STREET
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-0000
Practice Address - Country:US
Practice Address - Phone:256-734-9472
Practice Address - Fax:256-734-9272
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00015459207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000086453Medicaid
AL000086453Medicaid
86453Medicare ID - Type Unspecified