MEDICARE: KENNETH BURTON JOHNSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RH0003X	Hematology & Oncology Physician	A79802	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063527711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH BURTON JOHNSON MD

Provider Business Mailing Address
First Line	:	769 MEDICAL CENTER CT
Second Line	:	SUITE 202
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-6660
Country	:	US
Telephone Number	:	619-482-8430
Fax Number	:	619-482-8005

Provider Business Practice Location Address
First Line	:	769 MEDICAL CENTER CT
Second Line	:	SUITE 202
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-6660
Country	:	US
Telephone Number	:	619-482-8430
Fax Number	:	619-482-8005

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/19/2012

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