Provider Demographics
NPI:1629153135
Name:JOHNSON, RICHARD CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CHARLES
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 1:320 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450
Mailing Address - Country:US
Mailing Address - Phone:815-942-5335
Mailing Address - Fax:815-942-3750
Practice Address - Street 1:320 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450
Practice Address - Country:US
Practice Address - Phone:815-942-5335
Practice Address - Fax:815-942-3750
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics