Healthcare Provider Details

I. General information

NPI: 1548284896
Provider Name (Legal Business Name): MELISSA D JOHNSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 GRAVOIS RD SUITE 210
FENTON MO
63026-7727
US

IV. Provider business mailing address

PO BOX 23340
SAINT LOUIS MO
63156-3340
US

V. Phone/Fax

Practice location:
  • Phone: 636-660-9850
  • Fax: 636-660-9851
Mailing address:
  • Phone: 636-660-9850
  • Fax: 636-660-9851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2004008550
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: