Healthcare Provider Details

I. General information

NPI: 1003221680
Provider Name (Legal Business Name): KEVIN DARNELL JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5101 WILLOW SPRINGS RD 2ND FLOOR
LA GRANGE IL
60525-2600
US

IV. Provider business mailing address

5101 WILLOW SPRINGS RD 2ND FLOOR
LA GRANGE IL
60525-2600
US

V. Phone/Fax

Practice location:
  • Phone: 708-245-8900
  • Fax: 708-245-5604
Mailing address:
  • Phone: 708-245-8900
  • Fax: 708-245-5604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125065696
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: