Provider Demographics
NPI:1972560449
Name:JOHNSON, KENNETH WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
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:PO BOX 491389
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-9389
Mailing Address - Country:US
Mailing Address - Phone:310-351-1495
Mailing Address - Fax:866-631-5338
Practice Address - Street 1:711 W COLLEGE ST
Practice Address - Street 2:SUITE M88
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-1163
Practice Address - Country:US
Practice Address - Phone:213-625-8825
Practice Address - Fax:213-625-8838
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0428328208100000X
CAG83706208100000X
MO2006028600208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
F93582Medicare UPIN