Provider Demographics
NPI:1730479932
Name:JOHNSON, DANE PADRAIC (MD)
Entity Type:Individual
Prefix:DR
First Name:DANE
Middle Name:PADRAIC
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-8200
Mailing Address - Fax:314-454-5244
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DIV SURG UROLOGY, STE 11C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-8200
Practice Address - Fax:314-454-5244
Is Sole Proprietor?:No
Enumeration Date:2011-04-09
Last Update Date:2024-04-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2017014171208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200043577Medicaid