Healthcare Provider Details

I. General information

NPI: 1306825864
Provider Name (Legal Business Name): KENNETH M JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 10/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 4TH ST NW
WATERTOWN SD
57201-1558
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 605-886-8471
  • Fax: 605-886-9317
Mailing address:
  • Phone: 605-886-8471
  • Fax: 605-886-9317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1375
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: