Provider Demographics
NPI:1043398852
Name:JOHNSON, CARL C (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:C
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 1:1 ERIE CT
Mailing Address - Street 2:SUITE 6040
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2566
Mailing Address - Country:US
Mailing Address - Phone:708-386-1301
Mailing Address - Fax:708-386-3053
Practice Address - Street 1:1 ERIE CT
Practice Address - Street 2:SUITE 6040
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2566
Practice Address - Country:US
Practice Address - Phone:708-386-1301
Practice Address - Fax:708-386-3053
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38603207V00000X
IL036134028207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology