Provider Demographics
NPI:1083682660
Name:JOHNSON, GARY A (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
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 1:8940 N WOOD SAGE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7822
Mailing Address - Country:US
Mailing Address - Phone:309-243-3000
Mailing Address - Fax:309-243-3274
Practice Address - Street 1:8940 N WOOD SAGE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7822
Practice Address - Country:US
Practice Address - Phone:309-243-3000
Practice Address - Fax:309-243-3000
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18538207VX0201X
KS04-34519207VX0201X
MO2012029926207VX0201X
IL036.12058207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR01799Medicare PIN
24R601805Medicare PIN
24R601805Medicare PIN