Basic Information
Provider Information | |||||||||
NPI: | 1871732503 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | CHRISTINA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25 CROSSROADS DR | ||||||||
Address2: | SUITE 306 | ||||||||
City: | OWINGS MILLS | ||||||||
State: | MD | ||||||||
PostalCode: | 211175421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4437382872 | ||||||||
FaxNumber: | 4437382713 | ||||||||
Practice Location | |||||||||
Address1: | 21 CROSSROADS DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | OWINGS MILLS | ||||||||
State: | MD | ||||||||
PostalCode: | 211175441 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105818140 | ||||||||
FaxNumber: | 4103560885 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2009 | ||||||||
LastUpdateDate: | 08/22/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 25MA08567200 | NJ | N |   | Allopathic & Osteopathic Physicians | Urology |   | 208800000X | 34470 | SC | N |   | Allopathic & Osteopathic Physicians | Urology |   | 208800000X | D0076185 | MD | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 254908500 | 05 | MD |   | MEDICAID |