Healthcare Provider Details

I. General information

NPI: 1902899438
Provider Name (Legal Business Name): DANIEL JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W 95TH ST STE 1200H
OAK LAWN IL
60453-2654
US

IV. Provider business mailing address

150 HARVESTER DR SUITE 300
BURR RIDGE IL
60527-5919
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-5463
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number036073529
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: