Provider Demographics
NPI:1124190939
Name:JOHNSON, DAVID SCOTT (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:SCOTT
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 1:602 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-3218
Mailing Address - Country:US
Mailing Address - Phone:843-664-9393
Mailing Address - Fax:
Practice Address - Street 1:602 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-3218
Practice Address - Country:US
Practice Address - Phone:843-479-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1222152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD12225Medicaid
SCAA0640Medicare ID - Type Unspecified
SCU61174Medicare UPIN