Provider Demographics
NPI:1184700825
Name:JOHNSON EYE CLINIC, P.A
Entity type:Organization
Organization Name:JOHNSON EYE CLINIC, P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:S
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-376-5535
Mailing Address - Street 1:702 10TH ST
Mailing Address - Street 2:PO BOX 726
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-2767
Mailing Address - Country:US
Mailing Address - Phone:507-376-5535
Mailing Address - Fax:507-376-4805
Practice Address - Street 1:702 10TH ST
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-2767
Practice Address - Country:US
Practice Address - Phone:507-376-5535
Practice Address - Fax:507-376-4805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4C624JOOtherBLUECROSSBLUESHIELD
MNC07296Medicare ID - Type UnspecifiedWPS