Provider Demographics
NPI:1346210465
Name:JOHNSON, GERALD T (OD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:T
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 1:174 ROUTE 94
Mailing Address - Street 2:
Mailing Address - City:BLAIRSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07825
Mailing Address - Country:US
Mailing Address - Phone:908-362-8257
Mailing Address - Fax:
Practice Address - Street 1:174 STATE HIGHWAY 94
Practice Address - Street 2:
Practice Address - City:BLAIRSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07825
Practice Address - Country:US
Practice Address - Phone:908-362-8257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJOAO003764152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1510908Medicaid
521425Medicare ID - Type Unspecified
NJ1510908Medicaid