Provider Demographics
NPI:1194113621
Name:JOHNSON, JOHN (OD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
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 1:6224 CAMP BOWIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-5525
Mailing Address - Country:US
Mailing Address - Phone:817-761-1716
Mailing Address - Fax:817-761-1726
Practice Address - Street 1:6224 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5525
Practice Address - Country:US
Practice Address - Phone:817-761-1716
Practice Address - Fax:817-761-1726
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8603152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist