MEDICARE: DR. KENDRICK DEWAYNE 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	207T00000X	Neurological Surgery Physician	330499	LA
2	207T00000X	Neurological Surgery Physician	125.063144	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	330499	OTHER	LA	LICENSE

General Provider Information

NPI Number	:	1790122141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENDRICK DEWAYNE JOHNSON M.D.

Provider Business Mailing Address
First Line	:	1430 TULANE AVE # 8047
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70112-2632
Country	:	US
Telephone Number	:	504-988-3524
Fax Number	:	504-988-7846

Provider Business Practice Location Address
First Line	:	1430 TULANE AVE # 8047
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70112-2632
Country	:	US
Telephone Number	:	504-988-3524
Fax Number	:	504-988-7846

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

Provider Enumeration Date	:	05/24/2013
Last Update Date	:	06/24/2026

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