Provider Demographics
NPI:1346464955
Name:DR. JAY D. JOHNSON, OPTOMETRIST, PLC
Entity Type:Organization
Organization Name:DR. JAY D. JOHNSON, OPTOMETRIST, PLC
Other - Org Name:JOHNSON VISION ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-701-4114
Mailing Address - Street 1:1120 RAMBLING OAKS DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072
Mailing Address - Country:US
Mailing Address - Phone:405-701-4114
Mailing Address - Fax:405-801-3689
Practice Address - Street 1:1120 RAMBLING OAKS DRIVE
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072
Practice Address - Country:US
Practice Address - Phone:405-701-4114
Practice Address - Fax:405-801-3689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
OK1085152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200083870BMedicaid
OK200083870BMedicaid