Provider Demographics
NPI:1871732818
Name:JOHNSON, KEINO J (DO)
Entity type:Individual
Prefix:DR
First Name:KEINO
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E CITY AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1724
Mailing Address - Country:US
Mailing Address - Phone:215-503-3838
Mailing Address - Fax:610-664-2945
Practice Address - Street 1:225 E CITY AVE STE 109
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1724
Practice Address - Country:US
Practice Address - Phone:215-503-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-16
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014159207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine