Basic Information
| Provider Information | |||||||||
| NPI: | 1861542532 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KEEGAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1565 N MAIN ST | ||||||||
| Address2: | STE 406 | ||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027202972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087302020 | ||||||||
| FaxNumber: | 5086770975 | ||||||||
| Practice Location | |||||||||
| Address1: | 1565 N MAIN ST | ||||||||
| Address2: | STE 406 | ||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027202972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087302020 | ||||||||
| FaxNumber: | 5086770975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 01/27/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MT188093 | PA | N | Allopathic & Osteopathic Physicians | Surgery | 207W00000X | D70263 | MD | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | MD13803 | RI | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 036679000 | 05 | MD | MEDICAID |