Provider Demographics
NPI:1528113669
Name:JOHNSON, SHARON LARUTH (OD)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:LARUTH
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 1:4205 TIMBER TRAIL CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-4623
Mailing Address - Country:US
Mailing Address - Phone:817-996-2881
Mailing Address - Fax:817-561-6474
Practice Address - Street 1:BLDG. 33003, BATALLION AVE.
Practice Address - Street 2:MONROE TROOP MEDICAL CLINIC
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-4752
Practice Address - Country:US
Practice Address - Phone:254-288-5087
Practice Address - Fax:254-287-3534
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4666TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU46042Medicare UPIN
TX00E72VMedicare ID - Type Unspecified