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NPI Code Detail

MEDICARE: DOMINIQUE LATRICE JOHNSON DO

MEDICARE: DOMINIQUE LATRICE JOHNSON DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician5151015221MI
2207Q00000XFamily Medicine Physician036-171797IL

General Provider Information

NPI Number : 1386218147
Entity Type Code : Individual
Provider Name (Legal Business Name) : DOMINIQUE LATRICE JOHNSON DO
Provider Business Mailing Address
First Line : 29373 NETWORK PL
Second Line :
City : CHICAGO
State : IL
Zip : 60673-1293
Country : US
Telephone Number : 847-390-5900
Fax Number :
Provider Business Practice Location Address
First Line : 901 E 95TH ST
Second Line :
City : CHICAGO
State : IL
Zip : 60619-7861
Country : US
Telephone Number : 312-878-9240
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/17/2021
Last Update Date : 09/12/2024

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