Provider Demographics
NPI:1841474731
Name:JOHNSON, DONALD J (OD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:J
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:PO BOX 759
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-0026
Mailing Address - Country:US
Mailing Address - Phone:541-488-1417
Mailing Address - Fax:
Practice Address - Street 1:3600 WASHBURN WAY
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4539
Practice Address - Country:US
Practice Address - Phone:541-883-1669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2008-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1642 ATI152W00000X, 152WC0802X
OR1642ATI152WP0200X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR031380Medicaid
OR031380Medicaid
ORU29943Medicare UPIN