Provider Demographics
NPI:1841283702
Name:JOHNSON, H. MIKE (OD)
Entity type:Individual
Prefix:DR
First Name:H.
Middle Name:MIKE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:HURSEL
Other - Middle Name:MIKE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8897
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:901 N WINSTEAD AVE STE 190
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-8712
Practice Address - Country:US
Practice Address - Phone:252-937-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1120152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909462Medicaid
NC246440HMedicare ID - Type UnspecifiedMEDICARE NUMBER
NC8909462Medicaid