Provider Demographics
NPI:1639317647
Name:JOHNSON, SARAH CARLOTA (PA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:CARLOTA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 HIGHLAND AVE
Mailing Address - Street 2:STE 5C
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1552
Mailing Address - Country:US
Mailing Address - Phone:630-964-2000
Mailing Address - Fax:630-964-6378
Practice Address - Street 1:3825 HIGHLAND AVE
Practice Address - Street 2:STE 5C
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1552
Practice Address - Country:US
Practice Address - Phone:630-964-2000
Practice Address - Fax:630-964-6378
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003336207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364010940Medicare PIN