Provider Demographics
NPI:1184638611
Name:JOHNSON, KATHERINE (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:KATHERINE
Other - Middle Name:HOOD
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:2075 RENAISSANCE PARK PL
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-2263
Practice Address - Country:US
Practice Address - Phone:919-655-0625
Practice Address - Fax:919-655-0627
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1367152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0903FOtherBLUE CROSS BLUE SHIELD NC
NC890903FMedicaid
27635OtherSPECTERA
561761019OtherTRICARE
2467089AMedicare ID - Type Unspecified