Provider Demographics
NPI:1154345486
Name:JOHNSON, ERIC J II (OD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:J
Last Name:JOHNSON
Suffix:II
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 1551
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-1551
Mailing Address - Country:US
Mailing Address - Phone:601-485-2368
Mailing Address - Fax:601-693-2174
Practice Address - Street 1:1301 20TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4121
Practice Address - Country:US
Practice Address - Phone:601-485-2368
Practice Address - Fax:601-693-2174
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS684152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS410048407OtherRAILROAD MEDICARE
ALCH6608OtherRAILROAD GROUP ID
MS00880212Medicaid
1942285564OtherGROUP NPI
ALP00281824OtherRAILROAD MEDICARE
640931945OtherTAX ID
AL051554358Medicaid
MSCH5554OtherRAILROAD MEDICARE GROUP
MSC02590Medicare ID - Type UnspecifiedGROUP PROVIDER ID
MSC02590Medicare PIN
ALI424Medicare PIN
640931945OtherTAX ID
ALCH6608OtherRAILROAD GROUP ID
MSCH5554OtherRAILROAD MEDICARE GROUP
AL051554358Medicaid