Provider Demographics
NPI:1194910950
Name:SCOTT JOHNSON VISIONCARE, P.A.
Entity type:Organization
Organization Name:SCOTT JOHNSON VISIONCARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-763-0760
Mailing Address - Street 1:PO BOX 1649
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72316-1649
Mailing Address - Country:US
Mailing Address - Phone:870-763-0760
Mailing Address - Fax:870-838-1051
Practice Address - Street 1:1005 N 6TH ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1707
Practice Address - Country:US
Practice Address - Phone:870-763-0760
Practice Address - Fax:870-838-1051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2479152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR134831722Medicaid
AR134831722Medicaid
AR1225530001Medicare NSC
ARDR7097Medicare PIN
ARU18478Medicare UPIN