Basic Information
| Provider Information | |||||||||
| NPI: | 1346209020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | WALLACE | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 726 | ||||||||
| Address2: | |||||||||
| City: | WORTHINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561870726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073765535 | ||||||||
| FaxNumber: | 5073764805 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 10TH ST | ||||||||
| Address2: | |||||||||
| City: | WORTHINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561872767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073765535 | ||||||||
| FaxNumber: | 5073764805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 03/03/2015 | ||||||||
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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 | 152W00000X | 2196 | MN | Y | Eye and Vision Services Providers | Optometrist | 152WC0802X | 2196 | MN | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
ID Information
| ID | Type | State | Issuer | Description | 63372 | 01 | MN | MPIN | OTHER | 970525200 | 05 | MN | MEDICAID |