Provider Demographics
NPI:1285793356
Name:JOHNSON, DENISE ROBERTS (MD)
Entity type:Individual
Prefix:DR
First Name:DENISE
Middle Name:ROBERTS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6973 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63130-2540
Mailing Address - Country:US
Mailing Address - Phone:314-862-7515
Mailing Address - Fax:314-862-9214
Practice Address - Street 1:6973 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:UNIVERSITY CITY
Practice Address - State:MO
Practice Address - Zip Code:63130-2540
Practice Address - Country:US
Practice Address - Phone:314-862-7515
Practice Address - Fax:314-862-9214
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9G45208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202402210Medicaid
MO43-1890673OtherTAX ID NUMBER
MO202402210Medicaid