Provider Demographics
NPI:1144774928
Name:JOHNSON, SAMANTHA MICHELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:MICHELLE
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 1:8640 GULANA AVE UNIT J2016
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-7321
Mailing Address - Country:US
Mailing Address - Phone:619-820-2756
Mailing Address - Fax:
Practice Address - Street 1:4545 E 3RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1656
Practice Address - Country:US
Practice Address - Phone:323-261-3098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33472152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist