Provider Demographics
NPI:1063527711
Name:JOHNSON, KENNETH BURTON (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:BURTON
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 1:769 MEDICAL CENTER CT
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6660
Mailing Address - Country:US
Mailing Address - Phone:619-482-8430
Mailing Address - Fax:619-482-8005
Practice Address - Street 1:769 MEDICAL CENTER CT
Practice Address - Street 2:SUITE 202
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6660
Practice Address - Country:US
Practice Address - Phone:619-482-8430
Practice Address - Fax:619-482-8005
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79802207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0100450Medicaid
CAGR0100450Medicaid
CAI15576Medicare UPIN