Provider Demographics
NPI:1558381996
Name:JOHNSON, ROBERT D (PT, MS, OCS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT, MS, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 N BRAINARD AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526
Mailing Address - Country:US
Mailing Address - Phone:312-953-7003
Mailing Address - Fax:312-642-3966
Practice Address - Street 1:100 EAST WALTON
Practice Address - Street 2:STE 700
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-642-3963
Practice Address - Fax:312-642-3966
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL96513Medicare PIN