Provider Demographics
NPI:1104113497
Name:JOHNSON, LEE MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:MICHAEL
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 1:800 MAIN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-3760
Mailing Address - Country:US
Mailing Address - Phone:503-842-5568
Mailing Address - Fax:
Practice Address - Street 1:800 MAIN AVE STE A
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3760
Practice Address - Country:US
Practice Address - Phone:503-842-5568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2022-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2698152W00000X
ORAT-4289152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist