Provider Demographics
NPI:1518994060
Name:JOHNSON, MARIA SMITH (OD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:SMITH
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:PO BOX 207261
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7261
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:2100 W CORNWALLIS DR STE J
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7015
Practice Address - Country:US
Practice Address - Phone:336-288-3937
Practice Address - Fax:336-288-8177
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1938152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOD00003838OtherLICENCE
GAOPT002326OtherGA
NC1938OtherLICENCE
IDODP100059OtherLICENCE
U99466Medicare UPIN