Provider Demographics
NPI:1407005218
Name:JOHNSON, EVAN DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:DEAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3310 W. MAIN STREET
Mailing Address - Street 2:SUITE 115
Mailing Address - City:ST. CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-4220
Mailing Address - Country:US
Mailing Address - Phone:630-232-2885
Mailing Address - Fax:630-232-9936
Practice Address - Street 1:3310 W. MAIN STREET
Practice Address - Street 2:SUITE 115
Practice Address - City:ST. CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-4220
Practice Address - Country:US
Practice Address - Phone:630-232-2885
Practice Address - Fax:630-232-9936
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.121856207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology