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 1:775 BUCKSKIN AVE W STE 1
Mailing Address - Street 2:
Mailing Address - City:PILLAGER
Mailing Address - State:MN
Mailing Address - Zip Code:56473-2509
Mailing Address - Country:US
Mailing Address - Phone:218-746-2020
Mailing Address - Fax:218-520-0654
Practice Address - Street 1:775 BUCKSKIN AVE W
Practice Address - Street 2:
Practice Address - City:PILLAGER
Practice Address - State:MN
Practice Address - Zip Code:56473-2509
Practice Address - Country:US
Practice Address - Phone:218-746-2020
Practice Address - Fax:218-520-0654
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2196152WC0802X, 152W00000X
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