Provider Demographics
NPI:1295111433
Name:JOHNSON, ERIKA DANIELLE (OD)
Entity type:Individual
Prefix:
First Name:ERIKA
Middle Name:DANIELLE
Last Name:JOHNSON
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 1:11608 SUMMIT CREST DR
Mailing Address - Street 2:APT 302
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-8337
Mailing Address - Country:US
Mailing Address - Phone:502-598-9671
Mailing Address - Fax:502-425-3973
Practice Address - Street 1:4101 TOWNE CENTER DR
Practice Address - Street 2:TARGET OPTICAL
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-4146
Practice Address - Country:US
Practice Address - Phone:502-425-7672
Practice Address - Fax:502-425-3973
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1984DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1984DTOtherSTATE LICENSE