Provider Demographics
NPI:1407079981
Name:CYNTHIA G JOHNSON OD SC
Entity Type:Organization
Organization Name:CYNTHIA G JOHNSON OD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:G
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-886-4629
Mailing Address - Street 1:6641 MARINER DR
Mailing Address - Street 2:# 1
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406
Mailing Address - Country:US
Mailing Address - Phone:262-886-4629
Mailing Address - Fax:
Practice Address - Street 1:2500 MAYFAIR RD
Practice Address - Street 2:DEAN AND FLETCHER
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-771-8999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2246035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38576600Medicaid
8778D0002Medicare ID - Type Unspecified
WI38576600Medicaid