Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | A101851 | CA |
N | 207XS0114X | Adult Reconstructive Orthopaedic Surgeon | A101851 | CA |
NPI | 1053591198 |
---|---|
Provider Name | Dr. Kelly Dean Johnston |
First Address | San Diego, CA 92123-2776 |
Second Address | San Diego, CA 92123-2776 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2007 |
Last Update Date | 06/11/2007 |