Provider Demographics
NPI:1386669075
Name:JOHNSON, DAVID A (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
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 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:611 W. PARK ST.
Practice Address - Street 2:OPTHALMOLOGY/OPTOMETRY
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801
Practice Address - Country:US
Practice Address - Phone:217-383-3150
Practice Address - Fax:217-383-4845
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009048152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0533210001OtherDMERC
ILP00180818OtherRAILROAD
ILV02673Medicare UPIN
V02673Medicare UPIN
IL6447860011Medicare NSC
ILP00180818OtherRAILROAD
ILIL3270024Medicare PIN