Provider Demographics
NPI:1023637733
Name:JOHNSON, DANIELLE RAE (OD)
Entity type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DANIELLE
Other - Middle Name:RAE
Other - Last Name:KOLSCHEFSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:8220 N CORNERSTONE DR STE A
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8683
Mailing Address - Country:US
Mailing Address - Phone:208-772-5539
Mailing Address - Fax:
Practice Address - Street 1:8220 N CORNERSTONE DR STE A
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8683
Practice Address - Country:US
Practice Address - Phone:208-772-5539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34593152WP0200X
390200000X
IDODP-100539152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA430443Medicaid