Healthcare Provider Details

I. General information

NPI: 1487572434
Provider Name (Legal Business Name): KEVIN B JOHNSON CRANIAL PROSTHESIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2569 COUNTRYSIDE BLVD BUILDING 20 SUITE 127
CLEARWATER FL
33761
US

IV. Provider business mailing address

2569 COUNTRYSIDE BLVD
CLEARWATER FL
33761-3581
US

V. Phone/Fax

Practice location:
  • Phone: 727-408-9049
  • Fax:
Mailing address:
  • Phone: 727-460-1221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberBB8897104
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: