1790786820 NPI number — KENNETH ALLAN JOHNSON M.D.

Table of content: KENNETH ALLAN JOHNSON M.D. (NPI 1790786820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790786820 NPI number — KENNETH ALLAN JOHNSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
KENNETH
Provider Middle Name:
ALLAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790786820
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
127 OAK RIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATESBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30458-9135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-871-6742
Provider Business Mailing Address Fax Number:
912-871-2563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 FAIR RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
STATESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30458-1698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-871-6742
Provider Business Practice Location Address Fax Number:
912-871-2563
Provider Enumeration Date:
08/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  037577 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00572041A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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