Healthcare Provider Details

I. General information

NPI: 1528529252
Provider Name (Legal Business Name): KEMMIAN DERRAIL JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST SLOT 820
LITTLE ROCK AR
72205-7101
US

IV. Provider business mailing address

3401 SPRINGHILL DR STE 400
NORTH LITTLE ROCK AR
72117-2928
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-7840
  • Fax:
Mailing address:
  • Phone: 501-945-3343
  • Fax: 501-945-0770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberE16519
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number325941
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: