Provider Demographics
NPI:1558449876
Name:JOHNSON, WENDELL WALTER
Entity Type:Individual
Prefix:MR
First Name:WENDELL
Middle Name:WALTER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12626 S ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:CALUMET PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60827-6111
Mailing Address - Country:US
Mailing Address - Phone:708-396-8923
Mailing Address - Fax:
Practice Address - Street 1:4735 N BEACON
Practice Address - Street 2:#109
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640
Practice Address - Country:US
Practice Address - Phone:773-293-4575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist