Provider Demographics
NPI:1699785410
Name:JOHNSON, KYLE DALE (OD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:DALE
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 1:1516 S 5TH ST E
Mailing Address - Street 2:
Mailing Address - City:LOUISBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66053-4186
Mailing Address - Country:US
Mailing Address - Phone:913-244-8655
Mailing Address - Fax:
Practice Address - Street 1:1104 E OHIO ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-2458
Practice Address - Country:US
Practice Address - Phone:660-864-7116
Practice Address - Fax:660-864-7124
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003014755152W00000X
KS1687152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU96514Medicare UPIN
MOK590000Medicare PIN