Basic Information
| Provider Information | |||||||||
| NPI: | 1790950897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | MAURICE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2722 MERRILEE DR | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036984483 | ||||||||
| FaxNumber: | 7036982176 | ||||||||
| Practice Location | |||||||||
| Address1: | 2722 MERRILEE DR | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036984483 | ||||||||
| FaxNumber: | 7036982176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | D0088050 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 0101245083 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0109 | 01 | VA | CAREFIRST BCBS | OTHER | 282568 | 01 | VA | KAISER PERMANENTE | OTHER | 9592327 | 01 | VA | AETNA - PPO | OTHER | 0101245083 | 01 | VA | MEDICAL LICENSE | OTHER | 3848144 | 01 | VA | AETNA - HMO | OTHER |