Provider Demographics
NPI:1184682312
Name:JOHNSON, MILLIE A (OD)
Entity Type:Individual
Prefix:DR
First Name:MILLIE
Middle Name:A
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:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:NC
Mailing Address - Zip Code:27504-0397
Mailing Address - Country:US
Mailing Address - Phone:919-894-2001
Mailing Address - Fax:919-894-3190
Practice Address - Street 1:304 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:NC
Practice Address - Zip Code:27504-1511
Practice Address - Country:US
Practice Address - Phone:919-894-2001
Practice Address - Fax:919-894-3190
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1327152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0934FOtherBCBS
NC890934FMedicaid
NC890934FMedicaid
NC2467951CMedicare ID - Type Unspecified
NC0794680001Medicare NSC
NC0934FOtherBCBS