Provider Demographics
NPI:1386699502
Name:JOHNSON, KENT MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:MICHAEL
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 1:14541 W. INDIAN SCHOOL RD.
Mailing Address - Street 2:STE. 600
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395
Mailing Address - Country:US
Mailing Address - Phone:623-535-5599
Mailing Address - Fax:623-535-4696
Practice Address - Street 1:14541 W INDIAN SCHOOL ROAD
Practice Address - Street 2:STE 600
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395
Practice Address - Country:US
Practice Address - Phone:623-535-5599
Practice Address - Fax:623-535-4696
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24416207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG95358Medicare UPIN
AZZ79090Medicare PIN