Provider Demographics
NPI:1952527715
Name:JOHNSON, MATTHEW ALLAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ALLAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:MATTHEW
Other - Middle Name:JOHNSON
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2001 COOLIDGE RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1378
Mailing Address - Country:US
Mailing Address - Phone:517-337-0316
Mailing Address - Fax:
Practice Address - Street 1:3600 CAPITAL AVE SW STE 203
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-9393
Practice Address - Country:US
Practice Address - Phone:269-979-6383
Practice Address - Fax:269-979-6381
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004428152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4901004428OtherSTATE LICENSE