Basic Information
| Provider Information | |||||||||
| NPI: | 1780668277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAIG | ||||||||
| FirstName: | JOHNETTA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 HOLLY HILLS AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631112410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144811615 | ||||||||
| FaxNumber: | 3143531310 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 HOLLY HILLS AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631112410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144811615 | ||||||||
| FaxNumber: | 3143531310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 07/01/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 107456 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003010581 | 01 | MO | CPIN | OTHER | 209702620 | 05 | MO | MEDICAID | 209702612 | 05 | MO | MEDICAID |