Provider Demographics
NPI:1669476495
Name:JOHNSON, WILLIAM LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:LEE
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 1:1 CHILDRENS PL
Mailing Address - Street 2:CB 8116
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1002
Mailing Address - Country:US
Mailing Address - Phone:314-454-2694
Mailing Address - Fax:314-454-2515
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-2694
Practice Address - Fax:314-454-2515
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1F192080P0201X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202878708Medicaid
ILENROLLEDMedicaid
2724V34311OtherHEALTHCARE USA
0200046OtherUHC
A13927Medicare UPIN
IL395470Medicare PIN
MO002012312Medicare PIN
000000010442OtherESSENCE
63927OtherGHP
4000498OtherAETNA
MO329672451Medicare PIN
IL0200800OtherUHC IL
08221955OtherBLUE SHIELD
IL28743OtherBCBS IL
MOP00047260Medicare PIN
IL110087737Medicare PIN