Healthcare Provider Details

I. General information

NPI: 1073975132
Provider Name (Legal Business Name): WILLIAM BECK JOHANSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2016
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 DUTCHMANS LN
LOUISVILLE KY
40205-3271
US

IV. Provider business mailing address

6200 DUTCHMANS LN
LOUISVILLE KY
40205-3271
US

V. Phone/Fax

Practice location:
  • Phone: 502-456-6200
  • Fax: 502-456-6655
Mailing address:
  • Phone: 502-456-6200
  • Fax: 24-566-6555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number60650
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License Number60650
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: