Provider Demographics
NPI:1578630141
Name:JOHNSON, KATHRYN ANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KATHYRN
Other - Middle Name:
Other - Last Name:BOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:UC BERKELEY SCHOOL OF OPTOMETRY
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94720-2020
Mailing Address - Country:US
Mailing Address - Phone:510-642-0945
Mailing Address - Fax:
Practice Address - Street 1:UC BERKELEY SCHOOL OF OPTOMETRY
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-4405
Practice Address - Country:US
Practice Address - Phone:510-642-0945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11608T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU95945Medicare UPIN
CASD0116081Medicare ID - Type Unspecified