Provider Demographics
NPI:1033318837
Name:ST. JOHN, JOHN B
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:ST. JOHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 NE 17TH CT
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305-3319
Mailing Address - Country:US
Mailing Address - Phone:954-701-5050
Mailing Address - Fax:
Practice Address - Street 1:1429 NE 17TH CT
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33305-3319
Practice Address - Country:US
Practice Address - Phone:954-701-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA46403174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist