MEDICARE: DR. MELISSA D JOHNSON DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	2004008550	MO

General Provider Information

NPI Number	:	1548284896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MELISSA D JOHNSON DO

Provider Business Mailing Address
First Line	:	PO BOX 23340
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63156-3340
Country	:	US
Telephone Number	:	636-660-9850
Fax Number	:	636-660-9851

Provider Business Practice Location Address
First Line	:	714 GRAVOIS RD
Second Line	:	SUITE 210
City	:	FENTON
State	:	MO
Zip	:	63026-7727
Country	:	US
Telephone Number	:	636-660-9850
Fax Number	:	636-660-9851

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	11/01/2018

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