Provider Demographics
NPI:1699702738
Name:JOHNSON, MICHAEL K (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 DELMAR BLVD.
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112
Mailing Address - Country:US
Mailing Address - Phone:314-367-7848
Mailing Address - Fax:314-367-2985
Practice Address - Street 1:11642 WEST FLORISSANT
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63033
Practice Address - Country:US
Practice Address - Phone:314-838-8220
Practice Address - Fax:314-838-8091
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7701207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200642233Medicaid
MOA11549Medicare UPIN