Provider Demographics
NPI:1407967102
Name:JOHNSON, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:M
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:PO BOX 4776
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-4776
Mailing Address - Country:US
Mailing Address - Phone:812-336-1690
Mailing Address - Fax:812-349-1311
Practice Address - Street 1:5521 W LINCOLN HWY STE 1A
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-1098
Practice Address - Country:US
Practice Address - Phone:219-769-8284
Practice Address - Fax:219-769-8298
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025146A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01025146AOtherIN LICENSE
IN01025146BOtherCSR
IN01025146BOtherCSR
D94914Medicare UPIN
IN01025146BOtherCSR