Provider Demographics
NPI:1285600437
Name:JOHNSON, KIMBERLY SUSAN (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:SUSAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 HUNTINGTON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-3189
Mailing Address - Country:US
Mailing Address - Phone:850-814-7987
Mailing Address - Fax:
Practice Address - Street 1:340 MAGNOLIA CIRCLE
Practice Address - Street 2:
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32403-5612
Practice Address - Country:US
Practice Address - Phone:850-283-7678
Practice Address - Fax:850-283-7620
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024311208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics