Basic Information
| Provider Information | |||||||||
| NPI: | 1396965919 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN S KRISTOFERSON MD PA | ||||||||
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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: | 04/26/2007 | ||||||||
| LastUpdateDate: | 08/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | KRISTOFERSON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | SEVERIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9403826757 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | F6842 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200002820 | 01 | TX | PALMETTO GBA RAILROAD | OTHER | 0020KD | 01 | TX | BCBS GROUP | OTHER | 1235124314 | 01 | TX | INDIVIDUAL NPI | OTHER | 1003801416 | 01 | TX | VICKIE KRAHL NPI INDIVI | OTHER | 8J2030 | 01 | TX | BCBS INDIVIDUAL | OTHER | 033570501 | 05 | TX | MEDICAID | 89N936 | 01 | TX | VICKIE BCBS | OTHER |