Provider Demographics
NPI:1447396460
Name:JOHNSON, GREGORY CHARLES (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:CHARLES
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 1:10202 149TH ST E # 101
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-3746
Mailing Address - Country:US
Mailing Address - Phone:253-841-2020
Mailing Address - Fax:253-770-7378
Practice Address - Street 1:10202 149TH ST E # 101
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-3746
Practice Address - Country:US
Practice Address - Phone:253-841-2020
Practice Address - Fax:253-770-7378
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3116TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB15897Medicare ID - Type Unspecified
WAU68307Medicare UPIN