Provider Demographics
NPI:1629365531
Name:JOHNSON, ERIC (OD)
Entity type:Individual
Prefix:
First Name:ERIC
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 1:675 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62049-1530
Mailing Address - Country:US
Mailing Address - Phone:217-532-5044
Mailing Address - Fax:217-532-2109
Practice Address - Street 1:675 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:IL
Practice Address - Zip Code:62049-1530
Practice Address - Country:US
Practice Address - Phone:217-532-5044
Practice Address - Fax:217-532-2109
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010442152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist