Provider Demographics
NPI:1548284896
Name:JOHNSON, MELISSA D (DO)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:636-660-9850
Mailing Address - Fax:636-660-9851
Practice Address - Street 1:714 GRAVOIS RD
Practice Address - Street 2:SUITE 210
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-7727
Practice Address - Country:US
Practice Address - Phone:636-660-9850
Practice Address - Fax:636-660-9851
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2018-11-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2004008550207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO918665649Medicare PIN