Healthcare Provider Details

I. General information

NPI: 1275551699
Provider Name (Legal Business Name): JEFFREY E JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 12/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL STE 6A/6B/12A
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

660 S EUCLID AVE CB 8233
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-514-3566
  • Fax: 314-514-3689
Mailing address:
  • Phone: 314-514-3500
  • Fax: 314-454-8865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number111944
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: