Provider Demographics
NPI:1659363265
Name:JOHNSON, STEVEN KIRK (OD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:KIRK
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:PO BOX 60160
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0160
Mailing Address - Country:US
Mailing Address - Phone:704-365-0555
Mailing Address - Fax:704-367-8122
Practice Address - Street 1:135 S SHARON AMITY RD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211
Practice Address - Country:US
Practice Address - Phone:704-365-0555
Practice Address - Fax:704-367-8120
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7909457Medicaid
NCT78806Medicare UPIN
NC7909457Medicaid
NC246585BMedicare PIN