Provider Demographics
NPI:1063500866
Name:JOHNSON, WILLIAM GEORGE (DC)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:GEORGE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 413
Mailing Address - Street 2:
Mailing Address - City:WINNEBAGO
Mailing Address - State:IL
Mailing Address - Zip Code:61088-0413
Mailing Address - Country:US
Mailing Address - Phone:815-335-2820
Mailing Address - Fax:815-335-2009
Practice Address - Street 1:502 N ELIDA ST
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:IL
Practice Address - Zip Code:61088-8946
Practice Address - Country:US
Practice Address - Phone:815-335-2820
Practice Address - Fax:815-335-2009
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0010182024OtherBLUE CROSS M& BLUE SHIELD
ILT37549Medicare UPIN
IL658310Medicare ID - Type Unspecified