Provider Demographics
NPI:1245496538
Name:JOHNSON, SARAH A (OD)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:A
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 1:1360 E VENICE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-9066
Mailing Address - Country:US
Mailing Address - Phone:941-480-2135
Mailing Address - Fax:
Practice Address - Street 1:15661 SAN CARLOS BLVD UNIT 4
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-2797
Practice Address - Country:US
Practice Address - Phone:239-887-3187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4329152W00000X
MA4678152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3091241Medicaid
MA110080863AMedicaid
MA769201Medicare PIN