Provider Demographics
NPI:1487417119
Name:JOHNSON, KEITH D
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12400 CEDAR KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-2774
Mailing Address - Country:US
Mailing Address - Phone:972-365-1370
Mailing Address - Fax:
Practice Address - Street 1:511 W BURLESON ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-3107
Practice Address - Country:US
Practice Address - Phone:972-365-1370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health