Provider Demographics
NPI:1114909694
Name:JOHNSON, LOREN MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:LOREN
Middle Name:MARK
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 1:203 W LOSEY ST
Mailing Address - Street 2:SUITE 1620
Mailing Address - City:SCOTT AFB
Mailing Address - State:IL
Mailing Address - Zip Code:62225-5207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 W LOSEY ST
Practice Address - Street 2:SUITE 1620
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225-5207
Practice Address - Country:US
Practice Address - Phone:618-229-6306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033282207Q00000X, 2083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine