Provider Demographics
NPI:1689786352
Name:JOHNSON, JEFFREY T (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:0N150 WINFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190
Mailing Address - Country:US
Mailing Address - Phone:630-665-1550
Mailing Address - Fax:630-665-3510
Practice Address - Street 1:0N150 WINFIELD ROAD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190
Practice Address - Country:US
Practice Address - Phone:630-665-1550
Practice Address - Fax:630-665-3510
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036050297208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036050297Medicaid
IL036050297Medicaid
IL247030Medicare PIN