Provider Demographics
NPI:1972583391
Name:JOHNSON, MICHAEL WAYNE (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:WAYNE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:5777 GREENBACK LN
Mailing Address - Street 2:STE. 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-2013
Mailing Address - Country:US
Mailing Address - Phone:916-231-0034
Mailing Address - Fax:916-231-0038
Practice Address - Street 1:5777 GREENBACK LN
Practice Address - Street 2:STE. 100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-2013
Practice Address - Country:US
Practice Address - Phone:916-231-0034
Practice Address - Fax:916-231-0038
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10133T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0101330Medicaid
CASD0101331Medicare PIN
CA4644360002Medicare NSC
CASD0101330Medicaid