Provider Demographics
NPI:1073612107
Name:JOHNSON, T K (OD)
Entity Type:Individual
Prefix:
First Name:T
Middle Name:K
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 1:5908 EASTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6748
Mailing Address - Country:US
Mailing Address - Phone:989-636-7200
Mailing Address - Fax:989-636-7210
Practice Address - Street 1:5908 EASTMAN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6748
Practice Address - Country:US
Practice Address - Phone:989-636-7200
Practice Address - Fax:989-636-7210
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002282152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9OOE665040OtherBLUE CROSS BLUE SHIELD
MI1547439Medicaid
MI1547439Medicaid
MI9OOE665040OtherBLUE CROSS BLUE SHIELD
MIT33266Medicare UPIN