Theodore Johnson, MD

Primary specialty

General Practice PhysicianTaxonomy code 208D00000X

License

0101279593 Issued in VA

Practice address

3410 Illinois St
Great Lakes, IL 60088-3120

Phone

(224) 610-8553

NPI assigned

Mar 3, 2022

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1646265600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1752019200000",
    "number": "1609523240",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "220 HOVEY RD",
            "city": "PENSACOLA",
            "state": "FL",
            "postal_code": "325081044"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3410 ILLINOIS ST",
            "city": "GREAT LAKES",
            "state": "IL",
            "postal_code": "600883120",
            "telephone_number": "224-610-8553"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JOHNSON",
        "first_name": "THEODORE",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2022-03-03",
        "last_updated": "2025-07-09",
        "certification_date": "2025-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "171000000X",
            "taxonomy_group": "",
            "desc": "Military Health Care Provider",
            "state": "VA",
            "license": "0101279593",
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": "VA",
            "license": "0101279593",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• James a Lovell FHCC
• Kathy Ann January, RN
• Molly Ann Jenkins, DDS
• Scott A Jensen, DMD
• David Robert Johnsen, NAVY IDC
• Pamela Elayne Jones Williamson, D.O.
• Darryl Lamar Jones, D.D.S.
• Jeffrey Vincent Jones, M.D.
• Robert Lewis Jucovics, DDS
• Alex Kamenetsky

• General Practice Physician in Great Lakes, IL
• Providers in Great Lakes, IL by specialty
• General Practice Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.