Provider Demographics
NPI:1538246855
Name:JOHNSON, KEVIN (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
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 1:313 E COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:IN
Mailing Address - Zip Code:46356-1707
Mailing Address - Country:US
Mailing Address - Phone:410-271-6747
Mailing Address - Fax:410-271-6747
Practice Address - Street 1:313 E COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:IN
Practice Address - Zip Code:46356-1707
Practice Address - Country:US
Practice Address - Phone:410-271-6747
Practice Address - Fax:410-271-6747
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA 1972152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDV06828Medicare UPIN