Provider Demographics
NPI:1124059316
Name:JOHNSON, KENNETH E (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
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 1:2323 N LAKE DR
Mailing Address - Street 2:BEHAVIORAL HEALTH, 7TH FLOOR
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4508
Mailing Address - Country:US
Mailing Address - Phone:414-291-1620
Mailing Address - Fax:414-291-5969
Practice Address - Street 1:2323 N LAKE DR
Practice Address - Street 2:BEHAVIORAL HEALTH, 7TH FLOOR
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4508
Practice Address - Country:US
Practice Address - Phone:414-291-1620
Practice Address - Fax:414-291-5969
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27684-0202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31466200Medicaid
D86955Medicare UPIN
WI000300108Medicare PIN