Provider Demographics
NPI:1902104003
Name:JOHNSON, ERICK (OD)
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 W DOLARWAY RD STE 2
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-8228
Mailing Address - Country:US
Mailing Address - Phone:509-925-1000
Mailing Address - Fax:509-925-2474
Practice Address - Street 1:2201 W DOLARWAY RD STE 2
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-8228
Practice Address - Country:US
Practice Address - Phone:509-925-1000
Practice Address - Fax:509-925-2474
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-14
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN390200000X152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2044049Medicaid