Provider Demographics
NPI:1073826608
Name:JOHNSON, KATIE LEA (OD)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:LEA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9401 JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:MABELVALE
Mailing Address - State:AR
Mailing Address - Zip Code:72103-2951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:424 N UNIVERSITY AVE STE 5AND6
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-3109
Practice Address - Country:US
Practice Address - Phone:501-663-1131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-25
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2651152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR184071722Medicaid
AR4T057G485Medicare PIN