Provider Demographics
NPI:1831107986
Name:JOHNSON, MACK WRAY (OD)
Entity Type:Individual
Prefix:DR
First Name:MACK
Middle Name:WRAY
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 1:301 NORTHRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-2735
Mailing Address - Country:US
Mailing Address - Phone:580-338-8437
Mailing Address - Fax:580-338-8361
Practice Address - Street 1:301 NORTHRIDGE CIR
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-2735
Practice Address - Country:US
Practice Address - Phone:580-338-8437
Practice Address - Fax:580-338-8361
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2159152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100764570AMedicaid
OK100764570AMedicaid