Provider Demographics
NPI:1821023979
Name:JOHNSON, ROGER DEAN (OD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:DEAN
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 1:702 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-2767
Mailing Address - Country:US
Mailing Address - Phone:507-376-5535
Mailing Address - Fax:507-376-4805
Practice Address - Street 1:702 10TH ST
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-2767
Practice Address - Country:US
Practice Address - Phone:507-376-5535
Practice Address - Fax:507-376-4805
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1545152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN454523100Medicaid
MN454523100Medicaid
MN400133206Medicare Oscar/Certification