Basic Information
| Provider Information | |||||||||
| NPI: | 1447627815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JARVIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 MAPLE DR | ||||||||
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| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125372020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2032 VETERANS BLVD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310213042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782723445 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | OPTO002920 | GA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.