Provider Demographics
NPI:1922360130
Name:JOHNSON, KAMILAH MERCEDES (OD)
Entity Type:Individual
Prefix:DR
First Name:KAMILAH
Middle Name:MERCEDES
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 STURGIS RD.
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92278-8275
Mailing Address - Country:US
Mailing Address - Phone:760-830-2117
Mailing Address - Fax:
Practice Address - Street 1:1145 STURGIS RD.
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278-8257
Practice Address - Country:US
Practice Address - Phone:760-830-2117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14328TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist