Provider Demographics
NPI:1518073113
Name:JOHNSON, CARRYE PRIMMER (OD)
Entity Type:Individual
Prefix:DR
First Name:CARRYE
Middle Name:PRIMMER
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 1:7249 STONES RIVER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46259-5807
Mailing Address - Country:US
Mailing Address - Phone:317-965-8554
Mailing Address - Fax:
Practice Address - Street 1:6020 E 82ND ST
Practice Address - Street 2:SPACE 810
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-4746
Practice Address - Country:US
Practice Address - Phone:317-842-2018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003032152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU78870Medicare UPIN