Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | R9G45 | MO |
N | 2080A0000X | Adolescent Medicine | R9G45 | MO |
NPI | 1285793356 |
---|---|
Provider Name | Dr. Denise Roberts Johnson |
First Address | University City, MO 63130-2540 |
Second Address | University City, MO 63130-2540 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/12/2006 |
Last Update Date | 12/12/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
202402210 | (05) | MO |
A13941 | (02) | MO |