Provider Demographics
NPI:1578557443
Name:JOHNSON, HEIDI L (OD,)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:L
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 1:2822 VENTURE DR
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-8631
Mailing Address - Country:US
Mailing Address - Phone:906-228-4401
Mailing Address - Fax:906-225-0460
Practice Address - Street 1:2822 VENTURE DR
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-8631
Practice Address - Country:US
Practice Address - Phone:906-228-4401
Practice Address - Fax:906-225-0460
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2024-04-10
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
MI4901003354152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3115352Medicaid
MI900E265343OtherBLUE CROSS BLUE SHIELD OF
MI900E265343OtherBLUE CROSS BLUE SHIELD OF
MI3115352Medicaid