Healthcare Provider Details

I. General information

NPI: 1285793356
Provider Name (Legal Business Name): DENISE ROBERTS JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6973 OLIVE BLVD
UNIVERSITY CITY MO
63130-2540
US

IV. Provider business mailing address

6973 OLIVE BLVD
UNIVERSITY CITY MO
63130-2540
US

V. Phone/Fax

Practice location:
  • Phone: 314-862-7515
  • Fax: 314-862-9214
Mailing address:
  • Phone: 314-862-7515
  • Fax: 314-862-9214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR9G45
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberR9G45
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: