Healthcare Provider Details

I. General information

NPI: 1588628739
Provider Name (Legal Business Name): KENNETH B JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12720 HILLCREST RD STE 300
DALLAS TX
75230-2089
US

IV. Provider business mailing address

9330 LBJ FWY STE 800
DALLAS TX
75243-4310
US

V. Phone/Fax

Practice location:
  • Phone: 214-814-1550
  • Fax: 214-814-1350
Mailing address:
  • Phone: 972-792-5700
  • Fax: 214-506-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberJ8608
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberJ8608
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberJ8608
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: