Provider Demographics
NPI:1457349508
Name:JOHNSON, KENNETH IAN (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:IAN
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 1:1555 INDIAN RIVER BLVD STE B210
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-7113
Mailing Address - Country:US
Mailing Address - Phone:772-257-8224
Mailing Address - Fax:772-252-3245
Practice Address - Street 1:1545 9TH ST SW
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32962-4312
Practice Address - Country:US
Practice Address - Phone:772-257-8224
Practice Address - Fax:772-252-3245
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73635207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME73635OtherSTATE LICENSE
FLME73635OtherVHN
FL578869751OtherTRICARE
FLBCBSOther35407
FLME73635OtherDCWO
FLME73635OtherUNITED BENEFITS
FL258874900Medicaid
FLME73635OtherDCWO
FL35407ZMedicare ID - Type Unspecified