Provider Demographics
NPI:1407973175
Name:JOHNSON, TAMMY (OD)
Entity Type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12731 NEW BRITTANY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3632
Mailing Address - Country:US
Mailing Address - Phone:239-215-6931
Mailing Address - Fax:239-274-0773
Practice Address - Street 1:3515 DEL PRADO BLVD S UNIT 4
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904
Practice Address - Country:US
Practice Address - Phone:239-542-4123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5464152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024626000Medicaid
IN18003216BOtherINDIANA THERAPEUTIC LICEN