Provider Demographics
NPI:1952656589
Name:MARK JOHNSON, O.D., PLLC
Entity Type:Organization
Organization Name:MARK JOHNSON, O.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:409-892-4790
Mailing Address - Street 1:6155 EASTEX FWY
Mailing Address - Street 2:SUITE #699
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-6718
Mailing Address - Country:US
Mailing Address - Phone:409-892-4790
Mailing Address - Fax:
Practice Address - Street 1:6155 EASTEX FWY
Practice Address - Street 2:SUITE #699
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-6718
Practice Address - Country:US
Practice Address - Phone:409-892-4790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX4495152W00000X
TXTX4495T152WC0802X, 156F00000X, 156FC0800X, 156FC0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Multi-Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Multi-Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty