Healthcare Provider Details

I. General information

NPI: 1922587377
Provider Name (Legal Business Name): KYLE JOHNSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 SW 75TH AVE
MIAMI FL
33155-2805
US

IV. Provider business mailing address

3451 NE 1ST AVE APT M202
MIAMI FL
33137-4052
US

V. Phone/Fax

Practice location:
  • Phone: 305-264-5252
  • Fax:
Mailing address:
  • Phone: 407-701-3335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPR513
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: