1174565378 NPI number — DR. DONNA SUE JOHNSON OD

Table of content: DR. DONNA SUE JOHNSON OD (NPI 1174565378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174565378 NPI number — DR. DONNA SUE JOHNSON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
DONNA
Provider Middle Name:
SUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OSBORNE
Provider Other First Name:
DONNA
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174565378
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
418 S POPLAR
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
CENTRALIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-533-4929
Provider Business Mailing Address Fax Number:
618-533-4929

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
418 S POPLAR
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
CENTRALIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-533-4929
Provider Business Practice Location Address Fax Number:
618-533-4929
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  046007821 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 046007821 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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