Provider Demographics
NPI:1235124314
Name:KRISTOFERSON, JOHN SEVERIN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SEVERIN
Last Name:KRISTOFERSON
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 1:3325 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
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTXF6842207X00000X
TXF6842207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200002820OtherPALMETTO GBA
TX8J2030OtherBCBS
TX0020KDOtherBCBS
TX0474740001OtherMEDICARE SUPPLIER NUMBER
TX0474740001Medicare NSC
TX0474740001OtherMEDICARE SUPPLIER NUMBER
TXOOGC69Medicare ID - Type Unspecified