Provider Demographics
NPI:1508230491
Name:JOH, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:JOH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 S LYTLE ST
Mailing Address - Street 2:UNIT 1N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4192
Mailing Address - Country:US
Mailing Address - Phone:617-285-5038
Mailing Address - Fax:
Practice Address - Street 1:240 E HURON ST
Practice Address - Street 2:SUITE 1-200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2909
Practice Address - Country:US
Practice Address - Phone:312-503-7975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.073767208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery