Healthcare Provider Details

I. General information

NPI: 1033208418
Provider Name (Legal Business Name): TODD ANDREW JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 11/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1765 N ELSTON AVE SUITE 110
CHICAGO IL
60642-1501
US

IV. Provider business mailing address

1765 N ELSTON AVE SUITE 110
CHICAGO IL
60642-1501
US

V. Phone/Fax

Practice location:
  • Phone: 773-276-1100
  • Fax: 773-276-1102
Mailing address:
  • Phone: 773-276-1100
  • Fax: 773-276-1102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number036110291
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036110291
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: