Provider Demographics
NPI:1366595639
Name:JOHNSON, KIMBERLY D (OD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:D
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:816 E ENOS DR
Mailing Address - Street 2:STE A
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-8205
Mailing Address - Country:US
Mailing Address - Phone:805-928-8878
Mailing Address - Fax:805-928-3358
Practice Address - Street 1:628 CALIFORNIA BLVD
Practice Address - Street 2:STE D
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2542
Practice Address - Country:US
Practice Address - Phone:805-545-7881
Practice Address - Fax:805-548-8785
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13046152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV12071Medicare UPIN