Provider Demographics
NPI:1558316034
Name:JOHNSON, KERI P (MD)
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:P
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 1:637 DUNN RD STE 102B
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1755
Mailing Address - Country:US
Mailing Address - Phone:314-921-4500
Mailing Address - Fax:314-921-1077
Practice Address - Street 1:637 DUNN RD STE 102B
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1755
Practice Address - Country:US
Practice Address - Phone:314-921-4500
Practice Address - Fax:314-921-1077
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003011032208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP86873Medicare UPIN