Provider Demographics
NPI:1134229404
Name:CHRISTIANSEN, JOHN MERRILL (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MERRILL
Last Name:CHRISTIANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E PIKES PEAK AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3641
Mailing Address - Country:US
Mailing Address - Phone:719-632-0264
Mailing Address - Fax:
Practice Address - Street 1:555 E PIKES PEAK AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3641
Practice Address - Country:US
Practice Address - Phone:719-632-0264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO20417207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO20417OtherSTATE LICENSE NUMBER
COCH17991OtherBLUE SHIELD
COC806714Medicare PIN
COCO20417OtherSTATE LICENSE NUMBER