Provider Demographics
NPI:1306677059
Name:JOHNSON, MALLORY JAYNE (OD)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:JAYNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 LOS ARBOLES LN
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76711-1188
Mailing Address - Country:US
Mailing Address - Phone:254-366-5526
Mailing Address - Fax:
Practice Address - Street 1:590 MEDICAL CENTER RD
Practice Address - Street 2:BLDG 36065
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-288-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist