Provider Demographics
NPI:1740383116
Name:JOHNSON, CHRISTOPHER DAVID (OD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:DAVID
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 1:986 SE UGLOW STREET
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338
Mailing Address - Country:US
Mailing Address - Phone:503-623-3538
Mailing Address - Fax:503-623-8112
Practice Address - Street 1:986 SE UGLOW STREET
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338
Practice Address - Country:US
Practice Address - Phone:503-623-3538
Practice Address - Fax:503-623-8112
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2925ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR298499Medicaid
212606OtherEYE MED VISION INSURANCE
DC7770OtherMEDICARE RAILROAD
U98156Medicare UPIN
ORR119427Medicare ID - Type Unspecified