MEDICARE: JOHNSON PEDIATRICS, P.C.

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	208000000X	Pediatrics Physician	R9G45	MO

General Provider Information

NPI Number	:	1790845436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHNSON PEDIATRICS, P.C.

Provider Business Mailing Address
First Line	:	6973 OLIVE BLVD.
Second Line	:
City	:	UNIVERSITY CITY
State	:	MO
Zip	:	63130
Country	:	US
Telephone Number	:	314-862-7515
Fax Number	:	314-862-9214

Provider Business Practice Location Address
First Line	:	6973 OLIVE BLVD
Second Line	:
City	:	UNIVERSITY CITY
State	:	MO
Zip	:	63130-2540
Country	:	US
Telephone Number	:	314-862-7515
Fax Number	:	314-862-9214

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DENISE ROBERTS JOHNSON
Credential	:	M.D.
Telephone Number	:	314-862-7515

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	08/22/2020

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