Basic Information
| Provider Information | |||||||||
| NPI: | 1003878448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10700 E GEDDES AVE | ||||||||
| Address2: | NO 200 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 E HAMPDEN AVE | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801132702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 04/07/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 29383 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 25044 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 04-36659 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 17551 | HI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1003878448 | 05 | WY | MEDICAID | 1679513196 | 05 | UT | MEDICAID | 200425020A | 05 | KS | MEDICAID | 200427030A | 05 | OK | MEDICAID | 1003878448 | 05 | UT | MEDICAID | 10025709000 | 05 | NE | MEDICAID | 2192451 | 05 | LA | MEDICAID | 84-059792913 | 05 | NE | MEDICAID | 300049154 | 01 | CO | RR RIA MEDICARE | OTHER | 300090607 | 01 | CO | RR DIA MEDICARE | OTHER | 418800 | 05 | AZ | MEDICAID | 02300136 | 01 | NY | NY MEDICAID | OTHER | P00720354 | 01 | NE | RR MCR NE | OTHER | XPY204569 | 01 | CA | CA MEDICAID | OTHER | 003135486A | 01 | GA | GA MEDICAID | OTHER | 053221001 | 01 | TX | TX MEDICAID | OTHER | 1003878448 | 05 | MT | MEDICAID | 1003878448 | 05 | MO | MEDICAID | 300090599 | 01 | CO | RR MIC MEDICARE | OTHER | 01293836 | 05 | CO | MEDICAID | 7617652 | 05 | NC | MEDICAID | 1003878448 | 05 | NV | MEDICAID | 104686220 | 01 | MI | MI MEDICAID | OTHER |