Provider Demographics
NPI:1396476727
Name:JOHNSON, SOPHIA ELIZABETH (OD)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:ELIZABETH
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 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1148 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7728
Practice Address - Country:US
Practice Address - Phone:616-396-8814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005641152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist