Provider Demographics
NPI:1023260569
Name:JOHNSON, DAVID MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
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 1:2756 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-5412
Mailing Address - Country:US
Mailing Address - Phone:903-593-2345
Mailing Address - Fax:903-593-4646
Practice Address - Street 1:2756 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-5412
Practice Address - Country:US
Practice Address - Phone:903-593-2345
Practice Address - Fax:903-593-4646
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7283TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX215445201Medicaid
TX7283TGOtherTEXAS OPTOMETRY BOARD