MEDICARE: STEPHANIE R. JOHNSON O.D.

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
1	152W00000X	Optometrist	46-7055	IL
2	152WV0400X	Vision Therapy Optometrist	046007055	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992843007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE R. JOHNSON O.D.

Provider Business Mailing Address
First Line	:	5401 S WENTWORTH AVE STE 14B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60609-6300
Country	:	US
Telephone Number	:	773-924-5292
Fax Number	:	773-373-3548

Provider Business Practice Location Address
First Line	:	5401 S WENTWORTH AVE STE 14B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60609-6300
Country	:	US
Telephone Number	:	773-924-5292
Fax Number	:	773-373-3548

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	01/18/2019

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