Provider Demographics
NPI:1356304794
Name:JOHNSON, DOUGLAS W (OD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62049-1530
Mailing Address - Country:US
Mailing Address - Phone:217-532-5044
Mailing Address - Fax:217-532-2109
Practice Address - Street 1:675 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:IL
Practice Address - Zip Code:62049-1530
Practice Address - Country:US
Practice Address - Phone:217-532-5044
Practice Address - Fax:217-532-2109
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007103152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL28789OtherMEDICARE ID-TYPE UNSPECIFIED
IL046007103Medicaid
T37528Medicare UPIN
656990Medicare ID - Type Unspecified