Provider Demographics
NPI:1790176402
Name:JOHNSON, TODD RICHARD
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:RICHARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 BLOOMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-2101
Mailing Address - Country:US
Mailing Address - Phone:217-356-1558
Mailing Address - Fax:217-356-8529
Practice Address - Street 1:819 BLOOMINGTON RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-2101
Practice Address - Country:US
Practice Address - Phone:217-356-1558
Practice Address - Fax:217-356-8529
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012564363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily