Provider Demographics
NPI:1922144344
Name:WEST PLAINS FOOT AND ANKLE CLINIC PC
Entity Type:Organization
Organization Name:WEST PLAINS FOOT AND ANKLE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND SOLO PRACITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:417-256-6536
Mailing Address - Street 1:1566 IMPERIAL CTR
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-1818
Mailing Address - Country:US
Mailing Address - Phone:417-256-6536
Mailing Address - Fax:417-256-1156
Practice Address - Street 1:1566 IMPERIAL CTR
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-1818
Practice Address - Country:US
Practice Address - Phone:417-256-6536
Practice Address - Fax:417-256-1156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000553261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000021470Medicare ID - Type UnspecifiedDR JOHNSON MEDICARE NUMB
MOT93224Medicare UPIN
MO3861260001Medicare NSC