Provider Demographics
NPI:1245386267
Name:JOHANSEN, JAY MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:MICHAEL
Last Name:JOHANSEN
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 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:7203 HODGSON MEMORIAL DR STE A
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-1525
Practice Address - Country:US
Practice Address - Phone:912-352-9356
Practice Address - Fax:912-352-9105
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002253152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA743071437AMedicaid
GA202I140067Medicare PIN
GA511I410083Medicare PIN