Provider Demographics
NPI:1245258292
Name:KIMBERLY JOHNSON OD LLC
Entity type:Organization
Organization Name:KIMBERLY JOHNSON OD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:308-537-2020
Mailing Address - Street 1:902 AVENUE D
Mailing Address - Street 2:STE 102 B
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-1900
Mailing Address - Country:US
Mailing Address - Phone:308-537-2020
Mailing Address - Fax:
Practice Address - Street 1:902 AVENUE D
Practice Address - Street 2:STE 102 B
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-1900
Practice Address - Country:US
Practice Address - Phone:308-537-2020
Practice Address - Fax:308-537-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2013-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1232152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE099868OtherMEDICARE GROUP PROVIDER NUMBER
NE10025277400Medicaid