Provider Demographics
NPI:1356655856
Name:JOHNSON, MICHAEL T (OD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:3100 MERIDIAN PARKE DR STE J
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-9424
Mailing Address - Country:US
Mailing Address - Phone:317-888-9755
Mailing Address - Fax:317-888-9768
Practice Address - Street 1:3100 MERIDIAN PARKE DR STE J
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-9424
Practice Address - Country:US
Practice Address - Phone:317-888-9755
Practice Address - Fax:317-888-9768
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL046.010372152W00000X
CAOPT13946TLG152W00000X
IN18003700B152W00000X
IN18003700A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist