Provider Demographics
NPI:1710090485
Name:JOHNSON, DARIN LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:DARIN
Middle Name:LEE
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 1:3118 NORTHVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLEHARBOR
Mailing Address - State:ND
Mailing Address - Zip Code:58531
Mailing Address - Country:US
Mailing Address - Phone:701-240-0812
Mailing Address - Fax:
Practice Address - Street 1:1525 31ST AVE SW
Practice Address - Street 2:SUITE E
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-2016
Practice Address - Country:US
Practice Address - Phone:701-857-6050
Practice Address - Fax:701-857-6052
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3022152W00000X
ND648152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND712844OtherMEDICARE PTAN
ND60447Medicaid