Healthcare Provider Details

I. General information

NPI: 1083682660
Provider Name (Legal Business Name): GARY A JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8940 N WOOD SAGE RD
PEORIA IL
61615-7822
US

IV. Provider business mailing address

8940 N WOOD SAGE RD
PEORIA IL
61615-7822
US

V. Phone/Fax

Practice location:
  • Phone: 309-243-3000
  • Fax: 309-243-3000
Mailing address:
  • Phone: 309-243-3000
  • Fax: 309-243-3274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number18538
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number04-34519
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number2012029926
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number036.12058
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: