MEDICARE: DR. KIMBERLY SUSAN JOHNSON M.D.

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	208000000X	Pediatrics Physician	024311	LA

General Provider Information

NPI Number	:	1285600437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIMBERLY SUSAN JOHNSON M.D.

Provider Business Mailing Address
First Line	:	1214 HUNTINGTON RIDGE RD
Second Line	:
City	:	LYNN HAVEN
State	:	FL
Zip	:	32444-3189
Country	:	US
Telephone Number	:	850-814-7987
Fax Number	:

Provider Business Practice Location Address
First Line	:	340 MAGNOLIA CIRCLE
Second Line	:
City	:	TYNDALL AFB
State	:	FL
Zip	:	32403-5612
Country	:	US
Telephone Number	:	850-283-7678
Fax Number	:	850-283-7620

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

Provider Enumeration Date	:	02/27/2006
Last Update Date	:	07/08/2007

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