Provider Demographics
NPI:1396190864
Name:JOHNSON, ALICIA MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:ALICIA
Other - Middle Name:MARIE
Other - Last Name:KOMINEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:23172 REIN AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-4102
Mailing Address - Country:US
Mailing Address - Phone:248-657-3862
Mailing Address - Fax:
Practice Address - Street 1:32443 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-1154
Practice Address - Country:US
Practice Address - Phone:586-415-0245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004955152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist