Healthcare Provider Details

I. General information

NPI: 1417922857
Provider Name (Legal Business Name): GREGORY L JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MAIN ST SUITE 100
PEORIA IL
61602-1005
US

IV. Provider business mailing address

900 MAIN ST SUITE 100
PEORIA IL
61602-1005
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-4908
  • Fax: 309-672-4272
Mailing address:
  • Phone: 309-672-4908
  • Fax: 309-672-4272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number036115494
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: