Provider Demographics
NPI:1588770770
Name:JOHNSON, MARK KENNETH (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:KENNETH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W BONITA AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2543
Mailing Address - Country:US
Mailing Address - Phone:417-274-1067
Mailing Address - Fax:
Practice Address - Street 1:6502 REGENT WOOD CT
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-6270
Practice Address - Country:US
Practice Address - Phone:417-274-1067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5264213E00000X
MO000553213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO302284112Medicaid
MO302284112Medicaid
MO000021470Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER