Basic Information
| Provider Information | |||||||||
| NPI: | 1699702738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 DELMAR BLVD. | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143677848 | ||||||||
| FaxNumber: | 3143672985 | ||||||||
| Practice Location | |||||||||
| Address1: | 11642 WEST FLORISSANT | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148388220 | ||||||||
| FaxNumber: | 3148388091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 08/11/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | R7701 | MO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 200642233 | 05 | MO | MEDICAID |