Provider Demographics
NPI:1376626275
Name:JOHNSON, WAYNE EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:WAYNE
Other - Middle Name:E
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:10900 LOS ALAMITOS BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2354
Mailing Address - Country:US
Mailing Address - Phone:562-431-1301
Mailing Address - Fax:562-594-0624
Practice Address - Street 1:10900 LOS ALAMITOS BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2354
Practice Address - Country:US
Practice Address - Phone:562-431-1301
Practice Address - Fax:562-594-0624
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5408T152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT70020Medicare UPIN
CAWOP5408HMedicare PIN