Provider Demographics
NPI:1578634937
Name:JOHNSON, MARY CATHERINE (OD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
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 1:303 12TH LN SW
Mailing Address - Street 2:
Mailing Address - City:ORONOCO
Mailing Address - State:MN
Mailing Address - Zip Code:55960-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3827 MARKETPLACE DR NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-3192
Practice Address - Country:US
Practice Address - Phone:507-536-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2042152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU01149Medicare UPIN