Provider Demographics
NPI:1679523716
Name:LUBIN JOHNSON, NIVA M (MD)
Entity type:Individual
Prefix:
First Name:NIVA
Middle Name:M
Last Name:LUBIN 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 1:3601 W 183RD ST
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-2409
Mailing Address - Country:US
Mailing Address - Phone:708-957-7623
Mailing Address - Fax:708-957-7948
Practice Address - Street 1:8541 S STATE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-5665
Practice Address - Country:US
Practice Address - Phone:773-488-2200
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE19013Medicare UPIN
IL905770Medicare ID - Type Unspecified