Provider Demographics
NPI:1407419187
Name:JOHNSON, LEA SIMONE (MD)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:SIMONE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 HIGHLANDS PLAZA DR E STE 220
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1351
Mailing Address - Country:US
Mailing Address - Phone:314-273-0195
Mailing Address - Fax:
Practice Address - Street 1:1110 HIGHLANDS PLAZA DR E STE 220
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1351
Practice Address - Country:US
Practice Address - Phone:314-273-0195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022035816207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine