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General NPI Number Information
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NPI Number | 1083682660
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Entity Type | Individual
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Provider Name | GARY A JOHNSON MD
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Gender | Male
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Dates
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Enumeration Date | 03/09/2006
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Last Update Date | 01/10/2019
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Provider Practice Location Address
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Address Line | 8940 N WOOD SAGE RD
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City | PEORIA
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State | IL
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Zip | 61615-7822
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Country | US
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Telephone | 309-243-3000
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Fax | 309-243-3000
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Provider Business Mailing Address
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Address Line | 8940 N WOOD SAGE RD
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City | PEORIA
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State | IL
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Zip | 61615-7822
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Country | US
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Telephone | 309-243-3000
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Fax | 309-243-3274
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VX0201X
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Taxonomy Name | Gynecologic Oncology Physician
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License Number | 18538
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 207VX0201X
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Taxonomy Name | Gynecologic Oncology Physician
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License Number | 04-34519
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License Number State | KS
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Taxonomy #3
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Taxonomy Code | 207VX0201X
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Taxonomy Name | Gynecologic Oncology Physician
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License Number | 2012029926
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License Number State | MO
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Taxonomy #4
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Taxonomy Code | 207VX0201X
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Taxonomy Name | Gynecologic Oncology Physician
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License Number | 036.12058
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License Number State | IL
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