Provider Demographics
NPI:1972528123
Name:JOHNSON, RACHEL L (OD)
Entity Type:Individual
Prefix:DR
First Name:RACHEL
Middle Name:L
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 1:3301 E CENTER STREET EXT
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46582-3909
Mailing Address - Country:US
Mailing Address - Phone:574-269-3828
Mailing Address - Fax:574-269-3848
Practice Address - Street 1:3301 E CENTER STREET EXT
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46582-3909
Practice Address - Country:US
Practice Address - Phone:574-269-3828
Practice Address - Fax:574-269-3848
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002823A152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200124290AMedicaid
IN5020720001Medicare NSC
IN200124290AMedicaid
INU62823Medicare UPIN
IN452320001Medicare PIN