Provider Demographics
NPI:1841391471
Name:JOHNSON, MICHAEL JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
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 1:8811 BLAKENEY PROFESSIONAL DR.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-6599
Mailing Address - Country:US
Mailing Address - Phone:704-926-3937
Mailing Address - Fax:704-926-3938
Practice Address - Street 1:8811 BLAKENEY PROFESSIONAL DR.
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6599
Practice Address - Country:US
Practice Address - Phone:704-926-3937
Practice Address - Fax:704-926-3938
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1458152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891234NMedicaid
4105287OtherMAMSI
NC5131920001OtherMEDICARE NFC
1234NOtherBC/BS NC
5399513OtherAETNA
D6432OtherMEDCOST
NC5131920001OtherMEDICARE NFC
5399513OtherAETNA
NC891234NMedicaid