Provider Demographics
NPI:1841413622
Name:DR JAY D JOHNSON OPTOMETRIST PLC
Entity Type:Organization
Organization Name:DR JAY D JOHNSON OPTOMETRIST PLC
Other - Org Name:HERITAGE VISION ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:405-360-6285
Mailing Address - Street 1:7000 CROSSROADS BLVD
Mailing Address - Street 2:SUITE 1152
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73149-3202
Mailing Address - Country:US
Mailing Address - Phone:405-632-2300
Mailing Address - Fax:405-632-2939
Practice Address - Street 1:7000 CROSSROADS BLVD
Practice Address - Street 2:SUITE 1152
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73149-3202
Practice Address - Country:US
Practice Address - Phone:405-632-2300
Practice Address - Fax:405-632-2939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200083870AMedicaid
OK200083870AMedicaid