Provider Demographics
NPI:1902804875
Name:JOHNSON, C STEPHEN (OD FAAO)
Entity Type:Individual
Prefix:DR
First Name:C STEPHEN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2551 SAN RAMON VALLEY BLV
Mailing Address - Street 2:STE 101
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1661
Mailing Address - Country:US
Mailing Address - Phone:925-743-1222
Mailing Address - Fax:925-743-1221
Practice Address - Street 1:2551 SAN RAMON VALLEY BLV
Practice Address - Street 2:STE 101
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1661
Practice Address - Country:US
Practice Address - Phone:925-743-1222
Practice Address - Fax:925-743-1221
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2008-10-14
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
CA5287T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00175769OtherRAILROAD MEDICARE PIN#
0859240001Medicare NSC
CASD0052870Medicare PIN
CAT09932Medicare UPIN