Provider Demographics
NPI:1396965919
Name:JOHN S KRISTOFERSON MD PA
Entity type:Organization
Organization Name:JOHN S KRISTOFERSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:SEVERIN
Authorized Official - Last Name:KRISTOFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-382-6757
Mailing Address - Street 1:3325 MEDPARK DR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-6898
Mailing Address - Country:US
Mailing Address - Phone:940-382-6757
Mailing Address - Fax:940-383-1894
Practice Address - Street 1:3325 MEDPARK DR
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210
Practice Address - Country:US
Practice Address - Phone:940-382-6757
Practice Address - Fax:940-383-1894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6842207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200002820OtherPALMETTO GBA RAILROAD
TX0020KDOtherBCBS GROUP
TX1235124314OtherINDIVIDUAL NPI
TX1003801416OtherVICKIE KRAHL NPI INDIVI
TX8J2030OtherBCBS INDIVIDUAL
TX033570501Medicaid
TX89N936OtherVICKIE BCBS
TX033570501Medicaid
TX8J2030OtherBCBS INDIVIDUAL
TX00GC69Medicare ID - Type Unspecified