Provider Demographics
NPI:1003890609
Name:JOHNSON, TRAVIS M (OD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 ROCK SPRINGS MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANA
Mailing Address - State:TN
Mailing Address - Zip Code:37037-5357
Mailing Address - Country:US
Mailing Address - Phone:651-230-3554
Mailing Address - Fax:
Practice Address - Street 1:140 JOE B JACKSON PKWY
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37127-7228
Practice Address - Country:US
Practice Address - Phone:615-203-9165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2763152W00000X
TN3158152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U78226Medicare UPIN
MN410001714Medicare ID - Type Unspecified