Provider Demographics
NPI:1841385937
Name:JOHNSON, LEE ROY W (MD)
Entity Type:Individual
Prefix:
First Name:LEE ROY
Middle Name:W
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 1:927 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2719
Mailing Address - Country:US
Mailing Address - Phone:217-224-4453
Mailing Address - Fax:217-224-9383
Practice Address - Street 1:927 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2719
Practice Address - Country:US
Practice Address - Phone:217-224-4453
Practice Address - Fax:217-224-9383
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0780852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA732001OtherBLUE CROSS BLUE SHIELD
MO202602405Medicaid
IL036078085Medicaid
LA732001OtherBLUE CROSS BLUE SHIELD
IL036078085Medicaid