Provider Demographics
NPI:1346407319
Name:JOHNSON, KIMBERLY LEONA (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LEONA
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 1:736 W 95TH ST
Mailing Address - Street 2:HALSTED MEDICAL CENTER
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1063
Mailing Address - Country:US
Mailing Address - Phone:773-487-0363
Mailing Address - Fax:708-229-6071
Practice Address - Street 1:736 W 95TH ST
Practice Address - Street 2:HALSTED MEDICAL CENTER
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-1063
Practice Address - Country:US
Practice Address - Phone:773-487-0363
Practice Address - Fax:708-229-6071
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-051280207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400092375Medicare PIN