Provider Demographics
NPI:1306863105
Name:JOHANNESSEN, KARL DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:KARL
Middle Name:DAVID
Last Name:JOHANNESSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 120759
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32912-0759
Mailing Address - Country:US
Mailing Address - Phone:321-298-7339
Mailing Address - Fax:321-751-7769
Practice Address - Street 1:6300 N WICKHAM RD
Practice Address - Street 2:UNIT 123
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2028
Practice Address - Country:US
Practice Address - Phone:321-751-7270
Practice Address - Fax:321-751-7769
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOPC 2589152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist