Provider Demographics
NPI:1164418943
Name:JOHNSON, ANDREW ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:ROBERT
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 1:4218 LINCOLNSHIRE DR
Mailing Address - Street 2:PO BOX 968
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2156
Mailing Address - Country:US
Mailing Address - Phone:618-242-8480
Mailing Address - Fax:618-242-8499
Practice Address - Street 1:4218 LINCOLNSHIRE DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2156
Practice Address - Country:US
Practice Address - Phone:618-242-8480
Practice Address - Fax:618-242-8499
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS28808208600000X
IL036121708208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121708Medicaid
IL036121708Medicaid
IL599560Medicare PIN