Provider Demographics
NPI:1871732503
Name:JOHNSON, KELLY CHRISTINA (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:CHRISTINA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CROSSROADS DR
Mailing Address - Street 2:SUITE 306
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5421
Mailing Address - Country:US
Mailing Address - Phone:443-738-2872
Mailing Address - Fax:443-738-2713
Practice Address - Street 1:21 CROSSROADS DR
Practice Address - Street 2:SUITE 200
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5441
Practice Address - Country:US
Practice Address - Phone:410-581-8140
Practice Address - Fax:410-356-0885
Is Sole Proprietor?:No
Enumeration Date:2009-02-19
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08567200208800000X
SC34470208800000X
MDD0076185208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD254908500Medicaid
MD292735YZUMedicare PIN