Provider Demographics
NPI:1891867347
Name:JOHNSON III, HEZIKIAH BRODRICK (OD)
Entity Type:Individual
Prefix:DR
First Name:HEZIKIAH
Middle Name:BRODRICK
Last Name:JOHNSON III
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 1:600 LONGBOW DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-8920
Mailing Address - Country:US
Mailing Address - Phone:229-438-5886
Mailing Address - Fax:
Practice Address - Street 1:2601 DAWSON RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-1674
Practice Address - Country:US
Practice Address - Phone:229-434-4313
Practice Address - Fax:229-883-7923
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1391152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU69791Medicare UPIN