Provider Demographics
NPI:1669217212
Name:JOHNSON, TREVOR (OD)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:
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 1:1630 CENTER ST W
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-0346
Mailing Address - Country:US
Mailing Address - Phone:507-316-0770
Mailing Address - Fax:507-701-0730
Practice Address - Street 1:1630 CENTER ST W
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-0346
Practice Address - Country:US
Practice Address - Phone:507-316-0770
Practice Address - Fax:507-701-0730
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3926152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist