Provider Demographics
NPI:1710919634
Name:JOHNSON, BRUCE L (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
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 1:1008 RIVERBURCH PKWY
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30721-8630
Mailing Address - Country:US
Mailing Address - Phone:706-278-0518
Mailing Address - Fax:706-275-9715
Practice Address - Street 1:1008 RIVERBURCH PKWY
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-8630
Practice Address - Country:US
Practice Address - Phone:706-278-0518
Practice Address - Fax:706-275-9715
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001333152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00514962AMedicaid
GAOPT001333OtherSTATE LICENSE
GA41ZCFXCMedicare ID - Type Unspecified
GAOPT001333OtherSTATE LICENSE