Provider Demographics
NPI:1962640052
Name:KEITH R. JOHNSON,M.D., P.A.
Entity type:Organization
Organization Name:KEITH R. JOHNSON,M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:RANDAL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-838-3888
Mailing Address - Street 1:1300 MURCHISON DR
Mailing Address - Street 2:SUITE, 310
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-4842
Mailing Address - Country:US
Mailing Address - Phone:915-838-3888
Mailing Address - Fax:915-838-3889
Practice Address - Street 1:1300 MURCHISON DR
Practice Address - Street 2:SUITE, 310
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4842
Practice Address - Country:US
Practice Address - Phone:915-838-3888
Practice Address - Fax:915-838-3889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-27
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4010174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH60430Medicare UPIN