Healthcare Provider Details

I. General information

NPI: 1396485157
Provider Name (Legal Business Name): SETH DANIEL JOHNSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 W 95TH ST
OAK LAWN IL
60453-2793
US

IV. Provider business mailing address

4220 W 95TH ST
OAK LAWN IL
60453-2793
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-5341
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1396485157
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: