Basic Information
| Provider Information | |||||||||
| NPI: | 1922587377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KYLE | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3451 NE 1ST AVE APT M202 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331374052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077013335 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 SW 75TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331552805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052645252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2018 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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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 | 213ES0103X | PR513 | FL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.