Provider Demographics
NPI:1497749931
Name:JOHNSON, VINCENT L (MD)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
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 1:300 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4200
Mailing Address - Country:US
Mailing Address - Phone:630-933-4700
Mailing Address - Fax:630-933-4427
Practice Address - Street 1:300 RANDALL RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4200
Practice Address - Country:US
Practice Address - Phone:630-933-4700
Practice Address - Fax:630-933-4427
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069759207RA0000X
IL036-096759208000000X
IL036096759208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE GROUP NUMBER
IL3631498336019001OtherCDPG HFS PAYEE ID
ILP00656803OtherMEDICARE RAILROAD
IL036096759Medicaid
IL0222075OtherBLUE CROSS GROUP NUMBER
IL036096759Medicaid