Provider Demographics
NPI:1154337202
Name:JOHNSON, CHRISTOPHER L (DPM)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 W 10TH ST
Mailing Address - Street 2:ATTN: EXECUTIVE DIRECTOR OF PHYSICIAN CLINICS
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2905
Mailing Address - Country:US
Mailing Address - Phone:573-364-9000
Mailing Address - Fax:
Practice Address - Street 1:1050 W 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-458-3402
Practice Address - Fax:573-426-6247
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000803213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO30531900Medicaid
MO365905405Medicaid
MO305351926Medicaid
MO305351918Medicaid
MO365905413Medicaid
MO305351918Medicaid
MO365905413Medicaid
MO30531900Medicaid
MOP00040654Medicare PIN
MO000012738Medicare PIN