Provider Demographics
NPI:1447370077
Name:JOHNSON-GROTE, ANDREA (OD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:JOHNSON-GROTE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:930 FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1336
Mailing Address - Country:US
Mailing Address - Phone:773-727-7665
Mailing Address - Fax:
Practice Address - Street 1:3136 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3117
Practice Address - Country:US
Practice Address - Phone:773-871-8210
Practice Address - Fax:773-871-4290
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL046009124152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist