Provider Demographics
NPI:1710079892
Name:JOHNSON, KARA DURICK (OD)
Entity Type:Individual
Prefix:DR
First Name:KARA
Middle Name:DURICK
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 1:12771 RIVERDALE BLVD NW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-1262
Mailing Address - Country:US
Mailing Address - Phone:763-421-1220
Mailing Address - Fax:763-421-1291
Practice Address - Street 1:12771 RIVERDALE BLVD NW
Practice Address - Street 2:SUITE 103
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-1262
Practice Address - Country:US
Practice Address - Phone:763-421-1220
Practice Address - Fax:763-421-1291
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2732152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN131053OtherUCARE
MN2200839OtherMEDICA
MN005323600OtherMN CARE
MN04S60DUOtherBLUE CROSS BLUE SHIELD
MN847271021774OtherPREFERRED ONE
MN2200840OtherMEDICA
MN921871021774OtherPREFERRED ONE
MN30187OtherEYEMED
MN005323600OtherMN CARE
MN921871021774OtherPREFERRED ONE