Provider Demographics
NPI:1144070566
Name:JOHNSON, OMAR
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 W SOUTH BOUNDARY ST
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5102
Mailing Address - Country:US
Mailing Address - Phone:419-490-0380
Mailing Address - Fax:
Practice Address - Street 1:1924 CHRISTIE ST # 3
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3901
Practice Address - Country:US
Practice Address - Phone:419-936-4617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator