Provider Demographics
NPI:1033215488
Name:JOHNSON-TONG, LARISA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:LARISA
Middle Name:MARIE
Last Name:JOHNSON-TONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:LARISA
Other - Middle Name:MARIE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4860 Y ST
Mailing Address - Street 2:SUITE 2400
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2307
Mailing Address - Country:US
Mailing Address - Phone:916-734-4641
Mailing Address - Fax:916-565-1620
Practice Address - Street 1:4860 Y ST
Practice Address - Street 2:SUITE 2400
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2307
Practice Address - Country:US
Practice Address - Phone:916-734-4641
Practice Address - Fax:916-565-1620
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12038T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU72838Medicare UPIN
CASD0120380Medicare ID - Type Unspecified