Provider Demographics
NPI:1003221680
Name:JOHNSON, KEVIN DARNELL (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DARNELL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 WILLOW SPRINGS RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2600
Mailing Address - Country:US
Mailing Address - Phone:708-245-8900
Mailing Address - Fax:708-245-5604
Practice Address - Street 1:5101 WILLOW SPRINGS RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2600
Practice Address - Country:US
Practice Address - Phone:708-245-8900
Practice Address - Fax:708-245-5604
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125065696390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program