Healthcare Provider Details

I. General information

NPI: 1336138809
Provider Name (Legal Business Name): KEVIN EARL JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 W WALL ST
RURAL HALL NC
27045-9308
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-969-9158
  • Fax: 336-969-4554
Mailing address:
  • Phone: 336-969-9158
  • Fax: 336-969-4554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number070497
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9801320
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: