Provider Demographics
NPI:1467450122
Name:JOHNSON, CARL WINSTON II (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:WINSTON
Last Name:JOHNSON
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:6703 W 159TH STREET
Mailing Address - Street 2:SUITE 110
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477
Mailing Address - Country:US
Mailing Address - Phone:708-331-1122
Mailing Address - Fax:708-331-5987
Practice Address - Street 1:6703 W 159TH STREET
Practice Address - Street 2:SUITE 110
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477
Practice Address - Country:US
Practice Address - Phone:708-331-1122
Practice Address - Fax:708-331-5987
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2018-09-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL36107266208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36107266Medicaid
IL363950/L93169OtherMEDICARE GROUP/PROVIDER
ILH69061Medicare UPIN