Basic Information
| Provider Information | |||||||||
| NPI: | 1184695710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1370 E VENICE AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342859082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414800500 | ||||||||
| FaxNumber: | 9414809322 | ||||||||
| Practice Location | |||||||||
| Address1: | 1370 E VENICE AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342859082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414800500 | ||||||||
| FaxNumber: | 9414809322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 11/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME58404 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | ME58404 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 372134500 | 05 | FL | MEDICAID | 203445431 | 01 | FL | TAX ID | OTHER |