Provider Demographics
NPI:1497195093
Name:JOHNSON, MOLLY O'SHAUGHNESSEY (OD)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:O'SHAUGHNESSEY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-4445
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:17495 LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-7581
Practice Address - Country:US
Practice Address - Phone:708-226-7000
Practice Address - Fax:708-388-5672
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5013152W00000X
IL046.010653152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist