Provider Demographics
NPI:1528334943
Name:JOHANSON, KATHLEEN (DO)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:JOHANSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 STOCKTON RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-2637
Mailing Address - Country:US
Mailing Address - Phone:845-641-8753
Mailing Address - Fax:
Practice Address - Street 1:905 STOCKTON RD
Practice Address - Street 2:
Practice Address - City:VALLEY COTTAGE
Practice Address - State:NY
Practice Address - Zip Code:10989-2637
Practice Address - Country:US
Practice Address - Phone:845-641-8753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY294456207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty