Provider Demographics
NPI:1275525701
Name:JOHNSON, CARL R (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:R
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:PO BOX 372
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-0372
Mailing Address - Country:US
Mailing Address - Phone:217-258-4080
Mailing Address - Fax:217-258-4084
Practice Address - Street 1:500 HEALTH CENTER DR
Practice Address - Street 2:SUITE 104
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9258
Practice Address - Country:US
Practice Address - Phone:217-258-4080
Practice Address - Fax:217-258-4084
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057126207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057126Medicaid
IL170490OtherPERSONALCARE HMO
IL0001520105OtherBLUE CROSS BLUE SHIELD
IL170490OtherPERSONALCARE HMO
IL646591Medicare ID - Type UnspecifiedWPS MEDICARE
IL036057126Medicaid