Provider Demographics
NPI:1124690656
Name:JOHAN, KENNETH (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:JOHAN
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 1:17350 HUMPHREYS PKWY UNIT 5303
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91387-3726
Mailing Address - Country:US
Mailing Address - Phone:312-478-4409
Mailing Address - Fax:
Practice Address - Street 1:16850 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5794
Practice Address - Country:US
Practice Address - Phone:760-241-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA195154207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program