Provider Demographics
NPI:1750510897
Name:JOHNSONBAUGH, MONICA (OD)
Entity Type:Individual
Prefix:DR
First Name:MONICA
Middle Name:
Last Name:JOHNSONBAUGH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:
Other - Last Name:BEDROYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-0617
Mailing Address - Country:US
Mailing Address - Phone:317-374-2225
Mailing Address - Fax:
Practice Address - Street 1:17135 KERCHEVAL AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1660
Practice Address - Country:US
Practice Address - Phone:313-473-9339
Practice Address - Fax:313-406-7254
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003575A152W00000X
OH5842152W00000X
MI4901004540152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400052552Medicare PIN