Provider Demographics
NPI:1114925773
Name:JOHNSON, DOUGLAS GORDON (OD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:GORDON
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 1:148 13TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-3127
Mailing Address - Country:US
Mailing Address - Phone:727-581-8706
Mailing Address - Fax:727-586-3743
Practice Address - Street 1:148 13TH ST SW
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3127
Practice Address - Country:US
Practice Address - Phone:727-581-8706
Practice Address - Fax:727-586-3743
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1753152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078244100Medicaid
20099ZMedicare PIN
FLT93896Medicare UPIN
FL0569350001Medicare NSC