Provider Demographics
NPI:1184774820
Name:JOHNSON, CURTIS E (OD)
Entity type:Individual
Prefix:
First Name:CURTIS
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 S CHARTER
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856
Mailing Address - Country:US
Mailing Address - Phone:217-762-2551
Mailing Address - Fax:217-762-5461
Practice Address - Street 1:102 S CHARTER
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856
Practice Address - Country:US
Practice Address - Phone:217-762-2551
Practice Address - Fax:217-762-5461
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007835152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U03055Medicare UPIN
IL6237070001Medicare NSC
395900Medicare PIN
ILK46276Medicare UPIN