Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 038006131 | IL |
N | 225100000X | Physical Therapist | 070.017873 | IL |
NPI | 1154482008 |
---|---|
Provider Name | Dr. David Andrew Johnson |
First Address | Lake Bluff, IL 60044-2530 |
Second Address | Lake Bluff, IL 60044-2530 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/12/2006 |
Last Update Date | 10/08/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
L73851 | PIN (01) | IL |
T39036 | (02) | IL |