Individual
DR. CARL R JOHNSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
500 HEALTH CENTER DR, SUITE 104, MATTOON, IL 61938-9258
(217) 258-4080
(217) 258-4084
Mailing address
PO BOX 372, MATTOON, IL 61938-0372
(217) 258-4080
(217) 258-4084
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
036057126
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0001520105
BLUE CROSS BLUE SHIELD
IL
05
—
036057126
—
IL
01
—
170490
PERSONALCARE HMO
IL
Enumeration date
08/19/2005
Last updated
01/27/2015
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