Provider Demographics
NPI:1063567808
Name:JOHNSON, JEFFREY ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
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 1:855 FEINBERG CT
Mailing Address - Street 2:STE 110
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013
Mailing Address - Country:US
Mailing Address - Phone:847-516-3111
Mailing Address - Fax:847-516-3133
Practice Address - Street 1:855 FEINBERG CT
Practice Address - Street 2:STE 110
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013
Practice Address - Country:US
Practice Address - Phone:847-516-3111
Practice Address - Fax:847-516-3133
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.007318152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007318Medicaid
IL046007318Medicaid
IL5965080001Medicare NSC
ILL75787Medicare PIN
ILMJ0216665OtherDEA
IL410042574Medicare PIN