Provider Demographics
NPI:1669529764
Name:JOHNSON, RODNEY CARL (OD)
Entity type:Individual
Prefix:
First Name:RODNEY
Middle Name:CARL
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 1:813 ALDEA DR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-2720
Mailing Address - Country:US
Mailing Address - Phone:760-754-1407
Mailing Address - Fax:
Practice Address - Street 1:3405 MARRON RD
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4673
Practice Address - Country:US
Practice Address - Phone:760-729-2903
Practice Address - Fax:760-729-2892
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8750T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0087500Medicare ID - Type Unspecified
CAU50346Medicare UPIN