Provider Demographics
NPI:1043235450
Name:JOHNSON, VICTORIA J (MD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:610 N. LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801
Practice Address - Country:US
Practice Address - Phone:218-383-6555
Practice Address - Fax:217-383-7069
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088253208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL250005082OtherRAILROAD
IL0533210001OtherDMERC
F83741Medicare UPIN
IL250005082OtherRAILROAD
IL0533210001OtherDMERC
ILF83741Medicare UPIN
IL6447860005Medicare NSC