Provider Demographics
NPI:1194906107
Name:JOHNSON, JOSEPH KEVIN (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:KEVIN
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 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:999 S FAIRMONT AVE STE 130
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5141
Practice Address - Country:US
Practice Address - Phone:209-366-2001
Practice Address - Fax:209-366-2024
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36524207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01365246Medicaid
CO841541697OtherBC/BS
CO841541697OtherUNITED HEALTH
CODD7190OtherRAIL ROAD MEDICARE
COG62546Medicare UPIN
CO01365246Medicaid