Provider Demographics
NPI:1548370620
Name:JOHNSON, ROURGER LYNN (OD)
Entity type:Individual
Prefix:
First Name:ROURGER
Middle Name:LYNN
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 1:5615 MEMORIAL DR STE G
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3256
Mailing Address - Country:US
Mailing Address - Phone:404-299-8180
Mailing Address - Fax:404-299-8147
Practice Address - Street 1:5615 MEMORIAL DR STE G
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3256
Practice Address - Country:US
Practice Address - Phone:404-299-8180
Practice Address - Fax:404-299-8147
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001721152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist