Healthcare Provider Details

I. General information

NPI: 1396155511
Provider Name (Legal Business Name): KEVIN JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 JAMES STREET
SYRACUSE NY
13203
US

IV. Provider business mailing address

129 SADDLESTONE PL APT A
CAMILLUS NY
13031-1688
US

V. Phone/Fax

Practice location:
  • Phone: 315-472-4471
  • Fax: 315-999-1377
Mailing address:
  • Phone: 248-914-8091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number294176
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number294176
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: