Provider Demographics
NPI:1568643864
Name:JOHNSON, MATTHEW TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TODD
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 1:111 ACACIA DR
Mailing Address - Street 2:UNIT 515
Mailing Address - City:INDIAN HEAD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60525-4404
Mailing Address - Country:US
Mailing Address - Phone:708-481-0100
Mailing Address - Fax:
Practice Address - Street 1:344 VICTORY DR
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2003
Practice Address - Country:US
Practice Address - Phone:708-481-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099289207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099289Medicaid
IL01634105OtherBLUE CROSS PROVIDER #
K06101Medicare PIN
H52936Medicare UPIN