Provider Demographics
NPI:1689646127
Name:FOZARD, JOHN GREGG (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GREGG
Last Name:FOZARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5383 STATE ROUTE 154
Mailing Address - Street 2:PO BOX 437
Mailing Address - City:PINCKNEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62274-3342
Mailing Address - Country:US
Mailing Address - Phone:618-357-2131
Mailing Address - Fax:618-357-3411
Practice Address - Street 1:5383 STATE ROUTE 154
Practice Address - Street 2:
Practice Address - City:PINCKNEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62274-3342
Practice Address - Country:US
Practice Address - Phone:618-357-2131
Practice Address - Fax:618-357-3411
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053225207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7320380OtherBCBS FMC GROUP PROVIDER #
IL080174912OtherMEDICARE RAILROAD
IL036053225Medicaid
IL2288028OtherUNITED HEALTHCARE ID
IL0027340080OtherBCBS PHYS PROVIDER #
IL034761OtherHEALTH ALLIANCE ID
IL122435OtherHEALTHLINK PROVIDER ID
IL080174912OtherMEDICARE RAILROAD
IL2288028OtherUNITED HEALTHCARE ID
IL034761OtherHEALTH ALLIANCE ID