Healthcare Provider Details

I. General information

NPI: 1497749931
Provider Name (Legal Business Name): VINCENT L JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 RANDALL RD
GENEVA IL
60134-4200
US

IV. Provider business mailing address

300 RANDALL RD
GENEVA IL
60134-4200
US

V. Phone/Fax

Practice location:
  • Phone: 630-933-4700
  • Fax: 630-933-4427
Mailing address:
  • Phone: 630-933-4700
  • Fax: 630-933-4427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number036069759
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-096759
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036096759
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: