Provider Demographics
NPI:1629069919
Name:JOHNSON, LISA L (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:C
Other - Last Name:LABIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5851 W 95TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2362
Mailing Address - Country:US
Mailing Address - Phone:708-499-9800
Mailing Address - Fax:708-499-6203
Practice Address - Street 1:5851 W 95TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2362
Practice Address - Country:US
Practice Address - Phone:708-499-9800
Practice Address - Fax:708-499-6203
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119477207VG0400X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400233068Medicare PIN
ILF400233070Medicare PIN
MA2076322Medicaid