Provider Demographics
NPI:1538107321
Name:MAO, JOHNSON (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNSON
Middle Name:
Last Name:MAO
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 1:2600 S MICHIGAN AVE
Mailing Address - Street 2:#403
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2506 N CLARK ST
Practice Address - Street 2:#282
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1848
Practice Address - Country:US
Practice Address - Phone:312-842-8210
Practice Address - Fax:312-842-8281
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36050106174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC42324Medicare UPIN
IL204774Medicare ID - Type Unspecified