Basic Information
| Provider Information | |||||||||
| NPI: | 1235124314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRISTOFERSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | SEVERIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3325 MEDPARK DR | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762106898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403826757 | ||||||||
| FaxNumber: | 9403831894 | ||||||||
| Practice Location | |||||||||
| Address1: | 3325 MEDPARK DR | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403826757 | ||||||||
| FaxNumber: | 9403831894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 08/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | TXF6842 | TX | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | F6842 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200002820 | 01 | TX | PALMETTO GBA | OTHER | 8J2030 | 01 | TX | BCBS | OTHER | 0020KD | 01 | TX | BCBS | OTHER | 0474740001 | 01 | TX | MEDICARE SUPPLIER NUMBER | OTHER |