Healthcare Provider Details

I. General information

NPI: 1396965919
Provider Name (Legal Business Name): JOHN S KRISTOFERSON MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
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 TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberF6842
License Number StateTX

VIII. Authorized Official

Name: JOHN SEVERIN KRISTOFERSON
Title or Position: PRESIDENT
Credential: MD
Phone: 940-382-6757