Provider Demographics
NPI:1023106309
Name:JOHNSON, ANSEL T (OD)
Entity type:Individual
Prefix:DR
First Name:ANSEL
Middle Name:T
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 1:12812 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2118
Mailing Address - Country:US
Mailing Address - Phone:708-385-0013
Mailing Address - Fax:708-385-1175
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:708-385-1175
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007826152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1636075OtherBCBSIL ID
IL046007826Medicaid
IL0718670001OtherDMERC PIN
IL363718601OtherTAX ID
410011831OtherRAIL ROAD MEDICARE PIN
IL046007826Medicaid
K02341Medicare PIN
IL0718670001OtherDMERC PIN