Provider Demographics
NPI:1992890586
Name:JOHNSEN, MELISSA L (OD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:L
Last Name:JOHNSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 S COLUMBIA RD STE 81
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6013
Mailing Address - Country:US
Mailing Address - Phone:701-795-1441
Mailing Address - Fax:
Practice Address - Street 1:2800 S COLUMBIA RD STE 81
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6013
Practice Address - Country:US
Practice Address - Phone:701-795-1441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND618152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2914OtherSTATE LICENSE
68-0560920OtherTAX IDENTIFICATION NUMBER
ND618OtherSTATE LICENSE
68-0560920OtherTAX IDENTIFICATION NUMBER
NDU98972Medicare UPIN