Provider Demographics
NPI:1972631752
Name:JOHNSON, GABRIEL JAY (OD)
Entity type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:JAY
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 1:918 W 4TH ST
Mailing Address - Street 2:APT. 1E
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-5804
Mailing Address - Country:US
Mailing Address - Phone:484-213-7757
Mailing Address - Fax:
Practice Address - Street 1:300 LYCOMING MALL CIR
Practice Address - Street 2:SUITE 264
Practice Address - City:PENNSDALE
Practice Address - State:PA
Practice Address - Zip Code:17756-8072
Practice Address - Country:US
Practice Address - Phone:570-546-8315
Practice Address - Fax:570-546-0312
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001770152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPA1770OtherEYEMED