Provider Demographics
NPI:1386733301
Name:JOHNSON, WILLIAM LEE (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:LEE
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 1:10730 SAINT FRANCIS DR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-2171
Mailing Address - Country:US
Mailing Address - Phone:601-656-2432
Mailing Address - Fax:
Practice Address - Street 1:1002 W BEACON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-3204
Practice Address - Country:US
Practice Address - Phone:601-656-2432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS634152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist