Provider Demographics
NPI:1083886113
Name:GEORGE K. JOHNSON, O.D., P.C.
Entity Type:Organization
Organization Name:GEORGE K. JOHNSON, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:O,D,
Authorized Official - Phone:602-978-4025
Mailing Address - Street 1:4025 W BELL RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-2750
Mailing Address - Country:US
Mailing Address - Phone:602-978-4025
Mailing Address - Fax:602-843-7101
Practice Address - Street 1:4025 W BELL RD
Practice Address - Street 2:SUITE 10
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-2750
Practice Address - Country:US
Practice Address - Phone:602-978-4025
Practice Address - Fax:602-843-7101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ117152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0901370OtherBLUE CROSS BLUE SHIELD
AZT41784Medicare UPIN
AZAZ0901370OtherBLUE CROSS BLUE SHIELD
AZ4749240001Medicare NSC