Provider Demographics
NPI:1346209020
Name:JOHNSON, WALLACE SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:SCOTT
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:PO BOX 726
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-0726
Mailing Address - Country:US
Mailing Address - Phone:507-376-5535
Mailing Address - Fax:507-376-4805
Practice Address - Street 1:702 10TH ST
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-2767
Practice Address - Country:US
Practice Address - Phone:507-376-5535
Practice Address - Fax:507-376-4805
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2196152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN63372OtherMPIN
MN970525200Medicaid
MN63372OtherMPIN
MN970525200Medicaid