Provider Demographics
NPI:1104822428
Name:JOHNSON, ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:172 CAMBRIDGE STREET
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01803
Mailing Address - Country:US
Mailing Address - Phone:781-272-4944
Mailing Address - Fax:781-272-8756
Practice Address - Street 1:172 CAMBRIDGE STREET
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803
Practice Address - Country:US
Practice Address - Phone:781-272-4944
Practice Address - Fax:781-272-8756
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3855152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CE5062OtherRAILROAD MEDICARE
JOW16020OtherBCBS PPD
JOW16028OtherBLUE SHIELD
0026613OtherNEIGHBORHOOD HEALTH
009318OtherNEIGHBORHOOD HEALTH
150576OtherHARVARD COMM HEALTH
497918OtherAETNA HMO
763552OtherSECURE HORIZONS /ECE
763552OtherTUFTS PPO
160676OtherHARVARD PILGRIM HMO
B20953401OtherCIGNA
763552OtherTUFTS ASSOCIATED HEALTH
763552OtherTUFTS TOTAL HEALTH PLAN
150576OtherPILGRIM HEALTH CARE
763662OtherSECURE HORIZONS/NEEC
JOW16028OtherHMO BLUE
MA0337901Medicaid
RIJOW1602BOtherBLUE SHIELD
JOW16020OtherBCBS PPD