Provider Demographics
NPI:1932223898
Name:JOHNSON, HOMER THOMAS II (MD)
Entity type:Individual
Prefix:DR
First Name:HOMER
Middle Name:THOMAS
Last Name:JOHNSON
Suffix:II
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:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1475 KISKER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-8781
Practice Address - Country:US
Practice Address - Phone:636-498-7880
Practice Address - Fax:636-498-7889
Is Sole Proprietor?:No
Enumeration Date:2007-03-18
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 97186207Q00000X
MONO. 2007001620207Q00000X
MO2007001620207QS1201X, 2080S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205475809Medicaid
MO105560095Medicare PIN