Provider Demographics
NPI:1326129420
Name:JOHNSON, JEFFREY C (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
Last Name:JOHNSON
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 1:7960 W RIFLEMAN ST.
Mailing Address - Street 2:SUITE #150
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9066
Mailing Address - Country:US
Mailing Address - Phone:208-377-8899
Mailing Address - Fax:
Practice Address - Street 1:7960 W RIFLEMAN ST
Practice Address - Street 2:SUITE #150
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9066
Practice Address - Country:US
Practice Address - Phone:208-377-8899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP843152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU23837Medicare UPIN
ID1592142Medicare ID - Type Unspecified