Provider Demographics
NPI:1013229442
Name:JOHNSON, JEFFERY BLAKE (OD)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:BLAKE
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 1:3805 WEST 28TH
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603
Mailing Address - Country:US
Mailing Address - Phone:870-536-4100
Mailing Address - Fax:870-536-9020
Practice Address - Street 1:3805 WEST 28TH
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603
Practice Address - Country:US
Practice Address - Phone:870-536-4100
Practice Address - Fax:870-536-9020
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2693152W00000X
IL046.010370152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203193Medicare PIN
ILCK5584Medicare PIN
ILCK5585Medicare PIN
IL203194Medicare PIN
IL203195Medicare PIN