Provider Demographics
NPI:1073579397
Name:JOHNSON, ROBERT B (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:B
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 1:825 S MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3218
Mailing Address - Country:US
Mailing Address - Phone:847-573-2802
Mailing Address - Fax:847-573-2837
Practice Address - Street 1:755 S. MILWAUKEE AVENUE, SUITE 263
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3266
Practice Address - Country:US
Practice Address - Phone:847-918-1500
Practice Address - Fax:847-918-1500
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213614207R00000X, 207RC0000X
IL036-121148207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01955022Medicaid
NYBB5898Medicare ID - Type UnspecifiedUPSTATE
NY01955022Medicaid
213592Medicare PIN
B99267Medicare UPIN