1770873101 NPI number — DR. KENDALL R JOHNSON M.D.

Table of content: DR. KENDALL R JOHNSON M.D. (NPI 1770873101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770873101 NPI number — DR. KENDALL R JOHNSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
KENDALL
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770873101
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
282 WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06106-3322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-545-8950
Provider Business Mailing Address Fax Number:
860-545-8959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
282 WASHINGTON ST
Provider Second Line Business Practice Location Address:
MEDICAL EDUCATION, 4H
Provider Business Practice Location Address City Name:
HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06106-3322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-545-9970
Provider Business Practice Location Address Fax Number:
860-545-9159
Provider Enumeration Date:
04/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080N0001X , with the licence number:  53035 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 53035 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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