Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | MO14398 | MO |
NPI | 1063480622 |
---|---|
Provider Name | Dr. John Anthony Johnson |
First Address | Columbia, MO 65203 |
Second Address | Columbia, MO 65203 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2006 |
Last Update Date | 18/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A14129 | (02) |