Healthcare Provider Details

I. General information

NPI: 1730286519
Provider Name (Legal Business Name): SARA JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 01/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

212 N RIDGELAND AVE
OAK PARK IL
60302-2323
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-9100
  • Fax:
Mailing address:
  • Phone: 708-383-0568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-107859
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: