1396965919 NPI number — JOHN S KRISTOFERSON MD PA

Table of content: (NPI 1396965919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396965919 NPI number — JOHN S KRISTOFERSON MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN S KRISTOFERSON MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396965919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3325 MEDPARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76210-6898
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-382-6757
Provider Business Mailing Address Fax Number:
940-383-1894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3325 MEDPARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-382-6757
Provider Business Practice Location Address Fax Number:
940-383-1894
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KRISTOFERSON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
SEVERIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
940-382-6757

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  F6842 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200002820 . This is a "PALMETTO GBA RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0020KD . This is a "BCBS GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1235124314 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1003801416 . This is a "VICKIE KRAHL NPI INDIVI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8J2030 . This is a "BCBS INDIVIDUAL" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 033570501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89N936 . This is a "VICKIE BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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