Provider Demographics
NPI:1538378690
Name:JOHNSON, KOE H (OD,)
Entity type:Individual
Prefix:DR
First Name:KOE
Middle Name:H
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 1:24710 WASHINGTON AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-8204
Mailing Address - Country:US
Mailing Address - Phone:951-461-2256
Mailing Address - Fax:951-461-7945
Practice Address - Street 1:24710 WASHINGTON AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-8204
Practice Address - Country:US
Practice Address - Phone:951-461-2256
Practice Address - Fax:951-461-7945
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 6705 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist