Basic Information
| Provider Information | |||||||||
| NPI: | 1952612020 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11475 OLDE CABIN RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631417128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149918200 | ||||||||
| FaxNumber: | 3145691787 | ||||||||
| Practice Location | |||||||||
| Address1: | 607 S NEW BALLAS RD | ||||||||
| Address2: | SUITE T1275 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142516844 | ||||||||
| FaxNumber: | 3142514337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 04/28/2017 | ||||||||
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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 | 2085R0001X | MD446623 | PA | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 2015001562 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 036140409 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1952612020 | 05 | MO | MEDICAID |