Provider Demographics
NPI:1912022641
Name:JOHNSON, LEONIDAS A (OD)
Entity Type:Individual
Prefix:
First Name:LEONIDAS
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5333 N SHERIDAN RD APT 26D
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-7323
Mailing Address - Country:US
Mailing Address - Phone:909-772-8567
Mailing Address - Fax:
Practice Address - Street 1:12812 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2118
Practice Address - Country:US
Practice Address - Phone:708-385-0013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8254152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No152W00000XEye and Vision Services ProvidersOptometrist