Provider Demographics
NPI:1992831135
Name:JOHNSON, JIMMY D (OD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:D
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 1:125 S 66TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2302
Mailing Address - Country:US
Mailing Address - Phone:402-489-9776
Mailing Address - Fax:402-489-9946
Practice Address - Street 1:17255 DAVENPORT ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-4092
Practice Address - Country:US
Practice Address - Phone:402-763-6466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE847152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE6967OtherBLUE CROSS
NENA1104001Medicare PIN
NE6967OtherBLUE CROSS
T01127Medicare UPIN