Provider Demographics
NPI:1972521235
Name:JOHNSON, PAUL STEPHEN (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:STEPHEN
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 1:681 MALL RING CIR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-6619
Mailing Address - Country:US
Mailing Address - Phone:702-450-9458
Mailing Address - Fax:702-454-8292
Practice Address - Street 1:681 MALL RING CIR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-6619
Practice Address - Country:US
Practice Address - Phone:702-450-9458
Practice Address - Fax:702-454-8292
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV413152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVT70055Medicare UPIN
NV102268Medicare ID - Type Unspecified