1295111433 NPI number — ERIKA DANIELLE JOHNSON O.D.

Table of content: ERIKA DANIELLE JOHNSON O.D. (NPI 1295111433)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295111433 NPI number — ERIKA DANIELLE JOHNSON O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
ERIKA
Provider Middle Name:
DANIELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295111433
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11608 SUMMIT CREST DR
Provider Second Line Business Mailing Address:
APT 302
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40229-8337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-598-9671
Provider Business Mailing Address Fax Number:
502-425-3973

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4101 TOWNE CENTER DR
Provider Second Line Business Practice Location Address:
TARGET OPTICAL
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40241-4146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-425-7672
Provider Business Practice Location Address Fax Number:
502-425-3973
Provider Enumeration Date:
08/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1984DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1984DT . This is a "STATE LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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