Healthcare Provider Details

I. General information

NPI: 1235124314
Provider Name (Legal Business Name): JOHN SEVERIN KRISTOFERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3325 MEDPARK DR
DENTON TX
76210
US

IV. Provider business mailing address

3325 MEDPARK DR
DENTON TX
76210-6898
US

V. Phone/Fax

Practice location:
  • Phone: 940-382-6757
  • Fax: 940-383-1894
Mailing address:
  • Phone: 940-382-6757
  • Fax: 940-383-1894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberTXF6842
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberF6842
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: