Provider Demographics
NPI:1689051195
Name:JOHNSON, TYAH DANIELLE (OD)
Entity Type:Individual
Prefix:MRS
First Name:TYAH
Middle Name:DANIELLE
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 1:5920 ANITA ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-5531
Mailing Address - Country:US
Mailing Address - Phone:214-886-8153
Mailing Address - Fax:
Practice Address - Street 1:6757 ARAPAHO RD STE 707
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-4073
Practice Address - Country:US
Practice Address - Phone:972-703-9070
Practice Address - Fax:972-703-9070
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-04
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9153TG152W00000X
SC1878152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist