Provider Demographics
NPI:1003032970
Name:JOHNSON, DELESIE PETRIC (OD)
Entity Type:Individual
Prefix:DR
First Name:DELESIE
Middle Name:PETRIC
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:DELESIE
Other - Middle Name:PETRIC
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:9307 FOXGROVE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-4107
Mailing Address - Country:US
Mailing Address - Phone:210-523-5276
Mailing Address - Fax:210-523-5276
Practice Address - Street 1:9307 FOXGROVE WAY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-4107
Practice Address - Country:US
Practice Address - Phone:210-523-5276
Practice Address - Fax:210-523-5276
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4493T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist