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General NPI Number Information
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NPI Number | 1114015351
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Entity Type | Individual
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Provider Name | LAWRENCE L JOHNSON M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/11/2006
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Last Update Date | 03/31/2017
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Provider Practice Location Address
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Address Line | 3310 W. MAIN STREET SUITE 115
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City | ST. CHARLES
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State | IL
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Zip | 60175
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Country | US
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Telephone | 630-232-2885
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Fax | 630-232-9936
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Provider Business Mailing Address
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Address Line | 3310 W. MAIN STREET SUITE 115
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City | ST. CHARLES
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State | IL
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Zip | 60175
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Country | US
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Telephone | 630-232-2885
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Fax | 630-232-9936
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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 | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 036 052717
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License Number State | IL
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