Healthcare Provider Details

I. General information

NPI: 1467420422
Provider Name (Legal Business Name): DAVID ROBERT JOHNSEN NAVY IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001A SIXTH STREET NAVAL HOSPITAL FISHER CLINIC
GREAT LAKES IL
60088
US

IV. Provider business mailing address

1130 BOB OFARRELL LN
BEACH PARK IL
60099-4512
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-2469
  • Fax: 847-688-2512
Mailing address:
  • Phone: 847-263-8867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: