Healthcare Provider Details

I. General information

NPI: 1053591198
Provider Name (Legal Business Name): KELLY DEAN JOHNSTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 FROST ST STE 200
SAN DIEGO CA
92123-2776
US

IV. Provider business mailing address

7910 FROST ST STE 200
SAN DIEGO CA
92123-2776
US

V. Phone/Fax

Practice location:
  • Phone: 858-278-8300
  • Fax: 858-278-1708
Mailing address:
  • Phone: 858-278-8300
  • Fax: 858-278-1708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA101851
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberA101851
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: