Provider Demographics
NPI:1174565378
Name:JOHNSON, DONNA SUE (OD)
Entity type:Individual
Prefix:DR
First Name:DONNA
Middle Name:SUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DONNA
Other - Middle Name:SUE
Other - Last Name:OSBORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:418 S POPLAR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801
Mailing Address - Country:US
Mailing Address - Phone:618-533-4929
Mailing Address - Fax:618-533-4929
Practice Address - Street 1:418 S POPLAR
Practice Address - Street 2:SUITE 5
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801
Practice Address - Country:US
Practice Address - Phone:618-533-4929
Practice Address - Fax:618-533-4929
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007821152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007821Medicaid
T38812Medicare UPIN
IL0376930001Medicare NSC
IL769890Medicare ID - Type Unspecified