Provider Demographics
NPI:1962838565
Name:JOHNSON, SAMUEL DAVID (OD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DAVID
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:PO BOX 648
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28340-0648
Mailing Address - Country:US
Mailing Address - Phone:910-628-8316
Mailing Address - Fax:910-628-5642
Practice Address - Street 1:204 IONA ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340-1616
Practice Address - Country:US
Practice Address - Phone:910-628-8316
Practice Address - Fax:910-628-5642
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2337152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist