Provider Demographics
NPI:1346292059
Name:JOHNSON, OWEN CANNON (OD)
Entity Type:Individual
Prefix:DR
First Name:OWEN
Middle Name:CANNON
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 1:302 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-2406
Mailing Address - Country:US
Mailing Address - Phone:843-546-2244
Mailing Address - Fax:843-546-2255
Practice Address - Street 1:302 CHURCH ST
Practice Address - Street 2:A
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-2406
Practice Address - Country:US
Practice Address - Phone:843-546-2244
Practice Address - Fax:843-546-2255
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1279152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD12791Medicaid
SCU97028Medicare UPIN
SCD12791Medicaid