Provider Demographics
NPI:1821589821
Name:JOHNSON, DREW (MD)
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:
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 1:1010 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6600
Practice Address - Country:US
Practice Address - Phone:806-599-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2021-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS4978207Q00000X, 208M00000X
390200000X
IL036.156907207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program