Provider Demographics
NPI:1538290218
Name:JOHNSON, MATTHEW JOSEPH (DPM)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 LARKIN AVE
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-5845
Mailing Address - Country:US
Mailing Address - Phone:847-931-9212
Mailing Address - Fax:847-222-7852
Practice Address - Street 1:2090 LARKIN AVE
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-5845
Practice Address - Country:US
Practice Address - Phone:847-931-9212
Practice Address - Fax:847-222-7852
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016 004881213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0005115612OtherAETNA
IL0210272OtherCIGNA
ILC 518820OtherUNITED AMERICAN INSURANCE
IL0001623386OtherBLUE CROSS AND BLUE SHIEL
IL518820Medicare ID - Type Unspecified
IL0001623386OtherBLUE CROSS AND BLUE SHIEL