Provider Demographics
NPI:1588680938
Name:DR HEIDI JOHNSON OD PC
Entity Type:Organization
Organization Name:DR HEIDI JOHNSON OD PC
Other - Org Name:SUPERIOR EYE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, OPTOMOTRIST
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD, FCOVD
Authorized Official - Phone:906-228-4401
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI152W00000X
152WP0200X
GU152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3115352Medicaid
MI900E211060OtherBCBS
MI900E265343OtherBCBS
MI0P16570Medicare PIN
MI3115352Medicaid
MI0674260001Medicare NSC