Provider Demographics
NPI:1912105057
Name:JOHNSON, STEPHEN ISSAC (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ISSAC
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 1:2800 W 95TH ST
Mailing Address - Street 2:BUSINESS DEVELOPMENT, 3N
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2701
Mailing Address - Country:US
Mailing Address - Phone:708-229-5420
Mailing Address - Fax:708-229-4209
Practice Address - Street 1:4901 W 79TH ST
Practice Address - Street 2:SUITE 10
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-1554
Practice Address - Country:US
Practice Address - Phone:708-422-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125052913207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine