Provider Demographics
NPI:1417922857
Name:JOHNSON, GREGORY L (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
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 1:900 MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1005
Mailing Address - Country:US
Mailing Address - Phone:309-672-4908
Mailing Address - Fax:309-672-4272
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1005
Practice Address - Country:US
Practice Address - Phone:309-672-4908
Practice Address - Fax:309-672-4272
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115494207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PENDINGMedicare ID - Type Unspecified