Independent US Healthcare Provider Directory & Public Medical Database
Active NPI 1609523240 Individual Practitioner Male Practitioner

Dr. Theodore Johnson , MD

General Practice • Great Lakes, IL

Professional Overview & Biography Verified Profile Summary

Dr. Theodore Johnson, MD is a registered healthcare professional specializing in General Practice in Great Lakes, IL. Practice services are available at 3410 ILLINOIS ST under active NPI credentials.

Practice Location & Contact Primary Location

Practice Address

3410 Illinois St

Great Lakes, IL 600883120

Telephone 2246108553

Specialty Benchmarks & Practice Insights

Comparative analytics for General Practice in Great Lakes, IL

Active Practitioner
Practitioner Clinical Experience
Active
City Avg: 10.5 Yrs
State Avg: 30.9 Yrs
Regional Practice Density
6 Specialists

Practicing in Great Lakes, IL (355 Statewide)

Telehealth Adoption Rate
0.0% Regional Adoption

In-Person Office Visits Only

Medicare Pricing Discount
67.4% Avg Savings

Under CMS Medicare Fee Schedule vs Standard Submitted Charges

Medical Specialties & State Licenses

CMS Verified: 2025-07-09
General Practice Primary Specialty

NUCC Taxonomy Code: 208D00000X

State License VA 0101279593

A physician who specializes in the general practice of diagnosing, treating, and managing patients with a variety of illnesses and conditions.

Military Health Care Provider

NUCC Taxonomy Code: 171000000X

State License VA 0101279593

Active duty military health care providers not otherwise classified who need to be separately identified for operational, clinical, or administrative processes.

Practice Associates & Co-Workers

Healthcare professionals and specialists practicing at this location or sharing practice phone/fax

7 Associated Practitioners
Adam Dziedzic , PA-C

Physician Assistant

NPI 1104935899

Physician Assistant (Certified)

Dr. Nick Johnson , PsyD

Psychologist - Clinical

NPI 1235198532

Doctor of Psychology (Psy.D.)

Herchel Mangune , PTA

Physical Therapy Assistant

NPI 1467272294

Physical Therapist Assistant

Dr. Malia Moreland , PhD

Psychologist - Clinical

NPI 1477349470

Doctor of Philosophy (Ph.D.)

David Torrez

Specialist/Technologist, Other

NPI 1588468383
Liam Kastner

Physical Therapy Assistant

NPI 1689468514

Career & Practice History Timeline

Chronological log of verified NPI updates, location relocations, credentials, and registry changes

11 Historical Events
📍
Updated Practice Location July 09, 2025

Registered at 3410 ILLINOIS ST, GREAT LAKES, IL 600883120 (Tel: 2246108553)

📍
Updated Practice Location August 22, 2023

Registered at 220 HOVEY RD, PENSACOLA, FL 325081044 (Tel: 7033958196)

📍
Updated Business Mailing Address August 22, 2023

Registered at 220 HOVEY RD, PENSACOLA, FL 325081044

👤
Provider Name / Credentials Updated August 22, 2023

Recorded as THEODORE JOHNSON, MD

🎓
Medical Taxonomy / Specialty Registered (Primary Specialty) August 22, 2023

Military Health Care Provider (License #0101279593 in VA)

NPI Profile Active March 03, 2022

NPI status registered as active in NPPES database

📍
Updated Practice Location March 03, 2022

Registered at 9040 JACKSON AVE, TACOMA, WA 984310001 (Tel: 2539680117)

📍
Updated Business Mailing Address March 03, 2022

Registered at 9040 JACKSON AVE, TACOMA, WA 984310001 (Tel: 2539680117)

👤
Provider Name / Credentials Updated March 03, 2022

Recorded as THEODORE JOHNSON

🎓
Medical Taxonomy / Specialty Registered (Primary Specialty) March 03, 2022

Student in an Organized Health Care Education/Training Program

🟢
Initial NPI Registration & Enumeration March 03, 2022

First registered as active Individual Practitioner in NPPES Database.

Patient & Community Reviews

Verified patient ratings, medical care experiences, and facility photos

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NPI Administrative Meta

NPI Number: 1609523240
Entity Type:
Individual Provider Physician, Nurse Practitioner, or Solo Healthcare Professional (Type 1 NPI)
Enumeration Date: March 03, 2022
Last Update: July 09, 2025
Sole Proprietor: No

Mailing Address

220 Hovey Rd

Pensacola, FL 325081044

Public Domain Record This profile contains public domain information published by CMS and NPPES under the Freedom of Information Act (FOIA).
⚠️ Medical Disclaimer

This directory listing is for informational purposes only and does not constitute medical advice, diagnosis, or physician endorsement. If you are experiencing a medical emergency, please call 911 immediately.