Provider Demographics
NPI:1275551699
Name:JOHNSON, JEFFREY E (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8233
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-514-3500
Mailing Address - Fax:314-454-8865
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:STE 6A/6B/12A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-514-3566
Practice Address - Fax:314-514-3689
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111944207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208699603Medicaid
ILENROLLEDMedicaid
MO069010232Medicare PIN
MO069010232Medicaid