Provider Demographics
NPI:1326030511
Name:JOHNSON, YOLANDRA L (MD)
Entity Type:Individual
Prefix:
First Name:YOLANDRA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60043-1002
Mailing Address - Country:US
Mailing Address - Phone:847-251-8661
Mailing Address - Fax:847-256-3412
Practice Address - Street 1:510 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:IL
Practice Address - Zip Code:60043-1002
Practice Address - Country:US
Practice Address - Phone:847-251-8661
Practice Address - Fax:847-256-3412
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086910207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110152884OtherRAILROAD MEDICARE
IL036086910OtherBLUE CROSS
IL036086910OtherBLUE CROSS
ILF69016Medicare UPIN