Provider Demographics
NPI:1730295692
Name:JOHNSON, NORMAN RICHARD (MD)
Entity Type:Individual
Prefix:MR
First Name:NORMAN
Middle Name:RICHARD
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:PO BOX 10010
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612-0010
Mailing Address - Country:US
Mailing Address - Phone:309-692-8100
Mailing Address - Fax:309-692-8106
Practice Address - Street 1:4625 N. UNIVERSITY ST.
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-648-3056
Practice Address - Fax:309-692-8106
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-059258207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0007232070OtherBCBS PROVIDER #
ILC41320Medicare UPIN