Provider Demographics
NPI:1689640310
Name:JOHNSON, SCOTT E (OD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:E
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 1:1005 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-1707
Mailing Address - Country:US
Mailing Address - Phone:870-763-0760
Mailing Address - Fax:870-838-1051
Practice Address - Street 1:1005 N 6TH ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1707
Practice Address - Country:US
Practice Address - Phone:870-763-0760
Practice Address - Fax:870-838-1051
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2479152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR134450722Medicaid
ARU18478Medicare UPIN
AR134450722Medicaid
ARP00958777Medicare PIN
AR1225530001Medicare NSC