Healthcare Provider Details

I. General information

NPI: 1629153135
Provider Name (Legal Business Name): RICHARD CHARLES JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 LIBERTY ST
MORRIS IL
60450
US

IV. Provider business mailing address

320 LIBERTY ST
MORRIS IL
60450
US

V. Phone/Fax

Practice location:
  • Phone: 815-942-5335
  • Fax: 815-942-3750
Mailing address:
  • Phone: 815-942-5335
  • Fax: 815-942-3750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: