Provider Demographics
NPI:1235683889
Name:JOHNSON, SUSAN LY (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LY
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 1:124 E BANDERA RD STE 403
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-2849
Mailing Address - Country:US
Mailing Address - Phone:830-331-8745
Mailing Address - Fax:830-331-8749
Practice Address - Street 1:124 E BANDERA RD STE 403
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-2849
Practice Address - Country:US
Practice Address - Phone:830-331-8745
Practice Address - Fax:830-331-8749
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-12
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8940-TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX376410201Medicaid