Provider Demographics
NPI:1841304052
Name:JOHNSON, MICHAEL LEE (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:114 W CAMELBACK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2563
Mailing Address - Country:US
Mailing Address - Phone:602-264-4104
Mailing Address - Fax:602-241-0687
Practice Address - Street 1:114 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2563
Practice Address - Country:US
Practice Address - Phone:602-264-4104
Practice Address - Fax:602-241-0687
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ1376152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist