Provider Demographics
NPI:1871614024
Name:JOHNSON, KIM M (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2895
Mailing Address - Country:US
Mailing Address - Phone:847-475-1224
Mailing Address - Fax:847-475-0150
Practice Address - Street 1:328 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2895
Practice Address - Country:US
Practice Address - Phone:847-475-1224
Practice Address - Fax:847-728-0077
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA79803207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology