Provider Demographics
NPI:1376629626
Name:LAWRENCE L. JOHNSON, M.D., S.C.
Entity Type:Organization
Organization Name:LAWRENCE L. JOHNSON, M.D., S.C.
Other - Org Name:LAWRENCE L. JOHNSON, M.D., S.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-232-2885
Mailing Address - Street 1:351 DELNOR DR
Mailing Address - Street 2:STE. 400
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134
Mailing Address - Country:US
Mailing Address - Phone:630-232-2885
Mailing Address - Fax:630-232-9936
Practice Address - Street 1:351 DELNOR DR
Practice Address - Street 2:STE. 400
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134
Practice Address - Country:US
Practice Address - Phone:630-232-2885
Practice Address - Fax:630-232-9936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-30
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052717207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036052717Medicaid
IL4500588OtherBLUE CROSS BLUE SHIELD
IL638090Medicare ID - Type Unspecified
ILD93800Medicare UPIN