Provider Demographics
NPI:1992773535
Name:JOHNSON, KEVIN R (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
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:PO BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5827
Mailing Address - Country:US
Mailing Address - Phone:870-934-5821
Mailing Address - Fax:870-934-5384
Practice Address - Street 1:2402 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2000
Practice Address - Country:US
Practice Address - Phone:662-690-8007
Practice Address - Fax:662-842-4653
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06202721Medicaid