Healthcare Provider Details

I. General information

NPI: 1467514588
Provider Name (Legal Business Name): KEITH W.V. JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 LAKE WOODLANDS DR 101
THE WOODLANDS TX
77382-2566
US

IV. Provider business mailing address

6701 LAKE WOODLANDS DR 101
THE WOODLANDS TX
77382-2566
US

V. Phone/Fax

Practice location:
  • Phone: 281-364-1122
  • Fax:
Mailing address:
  • Phone: 281-364-1122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberM6213
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: