Basic Information
| Provider Information | |||||||||
| NPI: | 1699738633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | GARETH | ||||||||
| MiddleName: | ROBERT-PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 753 JOHNNIE DODDS BLVD | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294643054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432843400 | ||||||||
| FaxNumber: | 8432843401 | ||||||||
| Practice Location | |||||||||
| Address1: | 2316 E MEYER BLVD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641321136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162764690 | ||||||||
| FaxNumber: | 8162764780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | R3052 | MO | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 04542100 | 01 | KS CITY BCBS | OTHER | BJ8012217 | 01 | DEA REGISTRATION# | OTHER | 705958 | 01 | KS | KS BCBS | OTHER |