Provider Demographics
NPI:1780710459
Name:JOHNSON, MICHAEL JOEL (OD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOEL
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 1:3900 PARK NICOLLET BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2505
Mailing Address - Country:US
Mailing Address - Phone:952-993-3150
Mailing Address - Fax:
Practice Address - Street 1:3900 PARK NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2505
Practice Address - Country:US
Practice Address - Phone:952-993-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2818152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN531P4JOOtherBCBS
MNOP6854OtherEYEMED
MNHP64503OtherHEALTH PARTNERS
MN133059OtherUCARE
MN22-03338OtherMEDICA
MNA01991033717OtherPREFERRED ONE
MNA01991033717OtherPREFERRED ONE