Provider Demographics
NPI:1083699458
Name:JOHNSON, RICHARD GENE (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GENE
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 1:2800 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:BIGGS PARK
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3000
Mailing Address - Country:US
Mailing Address - Phone:910-738-6464
Mailing Address - Fax:910-738-4944
Practice Address - Street 1:2800 N ELM ST
Practice Address - Street 2:
Practice Address - City:BIGGS PARK
Practice Address - State:NC
Practice Address - Zip Code:28358-3000
Practice Address - Country:US
Practice Address - Phone:910-738-6464
Practice Address - Fax:910-738-4944
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC1368152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890183YMedicaid
NC890183YMedicaid
2469959Medicare ID - Type Unspecified