Provider Demographics
NPI:1407887755
Name:JOHNSON, KIMBERLY A (OD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
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 1:1214 COUNTRYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-2500
Mailing Address - Country:US
Mailing Address - Phone:308-537-3166
Mailing Address - Fax:
Practice Address - Street 1:902 AVENUE D STE 102B
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-1955
Practice Address - Country:US
Practice Address - Phone:308-537-2020
Practice Address - Fax:308-537-2280
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1232152W00000X, 152WC0802X, 152WL0500X, 152WV0400X, 152WP0200X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE2804450OtherMEDICARE PROVIDER NUMBER
NE10025277400Medicaid
NE10025277400Medicaid