Provider Demographics
NPI:1740296763
Name:JOHNSON, LYNN DAVIS (OD)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:DAVIS
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 1:1103 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-8660
Mailing Address - Country:US
Mailing Address - Phone:772-589-8654
Mailing Address - Fax:772-581-3810
Practice Address - Street 1:1103 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-8660
Practice Address - Country:US
Practice Address - Phone:772-589-8654
Practice Address - Fax:772-581-3810
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP2938152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20646OtherBLUE CROSS BLUE SHIELD
FLP0223315OtherRAILROAD MEDICARE
FL20646XMedicare ID - Type Unspecified
U58581Medicare UPIN