Provider Demographics
NPI:1972581478
Name:JOHNSON JR., ROBERT JAMES (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JAMES
Last Name:JOHNSON JR.
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 1:600 LIGONIER ST
Mailing Address - Street 2:
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650-1426
Mailing Address - Country:US
Mailing Address - Phone:724-537-5358
Mailing Address - Fax:
Practice Address - Street 1:600 LIGONIER ST
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-1426
Practice Address - Country:US
Practice Address - Phone:724-537-5358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG 1079152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA007052715Medicaid
PA0603430001Medicare PIN
PAT-28613Medicare UPIN
PA007052715Medicaid
PA094799UMZMedicare ID - Type UnspecifiedGROUP