Provider Demographics
NPI:1144439712
Name:JOHNSON, TAMMRA ROESENER (OD)
Entity type:Individual
Prefix:DR
First Name:TAMMRA
Middle Name:ROESENER
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 REMINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-2911
Mailing Address - Country:US
Mailing Address - Phone:970-482-4700
Mailing Address - Fax:970-482-0966
Practice Address - Street 1:412 REMINGTON ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-2911
Practice Address - Country:US
Practice Address - Phone:970-482-4700
Practice Address - Fax:970-482-0966
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1292152W00000X, 152WC0802X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy