MEDICARE: DR. KEITH 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	207P00000X	Emergency Medicine Physician	G3499	TX
2	2083P0500X	Preventive Medicine/Occupational Environmental Medicine Physician	G3499	TX

General Provider Information

NPI Number	:	1912966615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH JOHNSON M.D.

Provider Business Mailing Address
First Line	:	28409 QUADRILLE LN
Second Line	:
City	:	FAIR OAKS RANCH
State	:	TX
Zip	:	78015-4633
Country	:	US
Telephone Number	:	210-520-8070
Fax Number	:	210-521-7688

Provider Business Practice Location Address
First Line	:	1904 GRANDSTAND DR
Second Line	:	SUITE 400
City	:	SAN ANTONIO
State	:	TX
Zip	:	78238-4508
Country	:	US
Telephone Number	:	210-520-8071
Fax Number	:	210-521-7688

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

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	11/23/2011

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