Basic Information
| Provider Information | |||||||||
| NPI: | 1275551848 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5092 MARION ST S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581046050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016408773 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3902 13TH AVE S STE 406 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581033357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012779555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | 607 | ND | Y | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
No ID Information.