Provider Demographics
NPI:1821281833
Name:JOHANNESEN, ERIC J (DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:JOHANNESEN
Suffix:
Gender:M
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:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-882-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-1201
Practice Address - Fax:573-884-4612
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012020845207RI0200X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE812OtherNE STATE LICENSE
MO152360624Medicare PIN