Provider Demographics
NPI:1629001474
Name:JOHNSON, JODIE J (OD)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:J
Last Name:JOHNSON
Suffix:
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 1:2364 W 12600 S
Mailing Address - Street 2:SUITE E
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7109
Mailing Address - Country:US
Mailing Address - Phone:801-446-7600
Mailing Address - Fax:801-446-0912
Practice Address - Street 1:2364 W 12600 S
Practice Address - Street 2:SUITE E
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7109
Practice Address - Country:US
Practice Address - Phone:801-446-7600
Practice Address - Fax:801-446-0912
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT963300949934152W00000X
UT330094-9934152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
UT3300949934152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Not Answered152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Not Answered152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
U74983Medicare UPIN