Provider Demographics
NPI:1861542532
Name:JOHNSON, KEEGAN (MD)
Entity type:Individual
Prefix:
First Name:KEEGAN
Middle Name:
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 1:1565 N MAIN ST
Mailing Address - Street 2:STE 406
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-2972
Mailing Address - Country:US
Mailing Address - Phone:508-730-2020
Mailing Address - Fax:508-677-0975
Practice Address - Street 1:1565 N MAIN ST
Practice Address - Street 2:STE 406
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-2972
Practice Address - Country:US
Practice Address - Phone:508-730-2020
Practice Address - Fax:508-677-0975
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT188093208600000X
MDD70263207W00000X
RIMD13803207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD036679000Medicaid
MD188867YYUMedicare PIN