Provider Demographics
NPI:1184703464
Name:JOHNSON, PHILLIP E (OD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3455 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 845
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-6501
Mailing Address - Country:US
Mailing Address - Phone:770-476-3606
Mailing Address - Fax:770-476-2818
Practice Address - Street 1:3455 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 845
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-6501
Practice Address - Country:US
Practice Address - Phone:770-476-3606
Practice Address - Fax:770-476-2818
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000841152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55435554SAMedicare ID - Type Unspecified
GAT86987Medicare UPIN