Provider Demographics
NPI:1659825669
Name:JOHNSON, STEPHANIE L (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1350 CONCOURSE AVE STE 142
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-4570
Mailing Address - Country:US
Mailing Address - Phone:901-701-2059
Mailing Address - Fax:901-259-2432
Practice Address - Street 1:1350 CONCOURSE AVE STE 142
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2020
Practice Address - Country:US
Practice Address - Phone:901-701-2059
Practice Address - Fax:901-259-2432
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3343152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist