Provider Demographics
NPI:1427130368
Name:JOHNSON, NATHAN D (OD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:D
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 1:4521 55TH ST
Mailing Address - Street 2:#10
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-3643
Mailing Address - Country:US
Mailing Address - Phone:269-274-4110
Mailing Address - Fax:
Practice Address - Street 1:5990 SANTO RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-1192
Practice Address - Country:US
Practice Address - Phone:858-571-8835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13071152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist