1275525701 NPI number — DR. CARL R JOHNSON M.D.

Table of content: DR. CARL R JOHNSON M.D. (NPI 1275525701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275525701 NPI number — DR. CARL R JOHNSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
CARL
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275525701
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 372
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTOON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61938-0372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-258-4080
Provider Business Mailing Address Fax Number:
217-258-4084

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 HEALTH CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
MATTOON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61938-9258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-258-4080
Provider Business Practice Location Address Fax Number:
217-258-4084
Provider Enumeration Date:
08/19/2005

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: 207R00000X , with the licence number:  036057126 , 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: 036057126 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 170490 . This is a "PERSONALCARE HMO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0001520105 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com