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General NPI Number Information
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NPI Number | 1396155511
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Entity Type | Individual
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Provider Name | KEVIN JOHNSON
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Gender | Male
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Dates
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Enumeration Date | 04/28/2014
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Last Update Date | 09/16/2024
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Provider Practice Location Address
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Address Line | 1045 JAMES STREET
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City | SYRACUSE
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State | NY
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Zip | 13203
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Country | US
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Telephone | 315-472-4471
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Fax | 315-999-1377
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Provider Business Mailing Address
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Address Line | 129 SADDLESTONE PL APT A
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City | CAMILLUS
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State | NY
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Zip | 13031-1688
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Country | US
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Telephone | 248-914-8091
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 294176
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 2084A0401X
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Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
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License Number | 294176
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License Number State | NY
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