Provider Demographics
NPI:1992843007
Name:JOHNSON, STEPHANIE R (OD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 S WENTWORTH AVE STE 14B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-6300
Mailing Address - Country:US
Mailing Address - Phone:773-924-5292
Mailing Address - Fax:773-373-3548
Practice Address - Street 1:5401 S WENTWORTH AVE STE 14B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-6300
Practice Address - Country:US
Practice Address - Phone:773-924-5292
Practice Address - Fax:773-373-3548
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46-7055152W00000X
IL046007055152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0046007055Medicaid
IL0046007055Medicaid
ILU09665Medicare UPIN