Provider Demographics
NPI:1255381307
Name:JOHNSON, WILLIAM A (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
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 1:3601 W 183RD ST
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-2409
Mailing Address - Country:US
Mailing Address - Phone:708-957-7623
Mailing Address - Fax:708-957-7948
Practice Address - Street 1:1701 W MONTEREY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-4257
Practice Address - Country:US
Practice Address - Phone:773-233-5850
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE49113Medicare UPIN
IL925140Medicare UPIN