Healthcare Provider Details

I. General information

NPI: 1881397164
Provider Name (Legal Business Name): TODD JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5551 WINGHAVEN BLVD STE 142
O FALLON MO
63368-3618
US

IV. Provider business mailing address

5551 WINGHAVEN BLVD STE 142
O FALLON MO
63368-3618
US

V. Phone/Fax

Practice location:
  • Phone: 636-685-7724
  • Fax:
Mailing address:
  • Phone: 636-685-7724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2026028277
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: