Provider Demographics
NPI:1417446097
Name:SAMUEL D JOHNSON OD PLLC
Entity Type:Organization
Organization Name:SAMUEL D JOHNSON OD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMEUL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:910-628-8316
Mailing Address - Street 1:PO BOX 648
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28340-0648
Mailing Address - Country:US
Mailing Address - Phone:910-628-8316
Mailing Address - Fax:910-628-5642
Practice Address - Street 1:204 IONA ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340-1616
Practice Address - Country:US
Practice Address - Phone:910-628-8316
Practice Address - Fax:910-628-5642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2337152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty