Provider Demographics
NPI:1558857292
Name:JOHNSON, GREGORY CHARLES II (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:CHARLES
Last Name:JOHNSON
Suffix:II
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 1:6724 51ST AVE E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98443-2335
Mailing Address - Country:US
Mailing Address - Phone:253-561-1376
Mailing Address - Fax:
Practice Address - Street 1:9600 VETERANS DR SW
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98493-0003
Practice Address - Country:US
Practice Address - Phone:253-583-1232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60861995152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOD60861995OtherWASHINGTON STATE DEPARTMENT OF HEALTH