Provider Demographics
NPI:1588656060
Name:JOHNSON, KRISTI (DO)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2840 W DAUPHIN ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19132-4627
Mailing Address - Country:US
Mailing Address - Phone:215-685-3405
Mailing Address - Fax:215-685-2440
Practice Address - Street 1:2840 W DAUPHIN ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19132-4627
Practice Address - Country:US
Practice Address - Phone:215-685-3405
Practice Address - Fax:215-685-2440
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010187L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G97105Medicare UPIN
PA028496D9NMedicare ID - Type Unspecified