Provider Demographics
NPI:1699478545
Name:GAVIN L JOHNSON OD LLC
Entity type:Organization
Organization Name:GAVIN L JOHNSON OD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OD
Authorized Official - Prefix:
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:435-730-3998
Mailing Address - Street 1:34 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-2527
Mailing Address - Country:US
Mailing Address - Phone:435-730-3998
Mailing Address - Fax:
Practice Address - Street 1:34 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-2527
Practice Address - Country:US
Practice Address - Phone:435-723-2485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-22
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty