Provider Demographics
NPI:1912043621
Name:JOHNSON, BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
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 1:800 W BIESTERFIELD ROAD
Mailing Address - Street 2:SUITE 4003
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-7306
Mailing Address - Country:US
Mailing Address - Phone:847-364-0800
Mailing Address - Fax:847-364-0854
Practice Address - Street 1:800 W BIESTERFIELD ROAD
Practice Address - Street 2:SUITE 4003
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007
Practice Address - Country:US
Practice Address - Phone:847-364-0800
Practice Address - Fax:847-364-0854
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078438207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078438Medicaid
56930Medicare ID - Type Unspecified
IL036078438Medicaid