Provider Demographics
NPI:1487616967
Name:JOHNSON, KEITH PATRICK (MD)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:PATRICK
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 1:85 HARRISTOWN ROAD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452
Mailing Address - Country:US
Mailing Address - Phone:844-366-8800
Mailing Address - Fax:844-366-8900
Practice Address - Street 1:85 HARRISTOWN ROAD
Practice Address - Street 2:SUITE 103
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452
Practice Address - Country:US
Practice Address - Phone:844-366-8800
Practice Address - Fax:844-366-8900
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07819000174400000X, 207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I26748Medicare UPIN
NJ089241Medicare ID - Type Unspecified