Healthcare Provider Details

I. General information

NPI: 1457336760
Provider Name (Legal Business Name): KENNETH LEE JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 DOCTORS DR SUITE N
KINSTON NC
28501-1584
US

IV. Provider business mailing address

701 DOCTORS DR SUITE N
KINSTON NC
28501-1584
US

V. Phone/Fax

Practice location:
  • Phone: 252-559-2200
  • Fax: 252-522-9778
Mailing address:
  • Phone: 252-559-2200
  • Fax: 252-522-9778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9801319
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: