Provider Demographics
NPI:1649249160
Name:JOHNSON, JULIE A (OD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:A
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 1:1513 S COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-4801
Mailing Address - Country:US
Mailing Address - Phone:920-725-1566
Mailing Address - Fax:920-725-8810
Practice Address - Street 1:1513 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-4801
Practice Address - Country:US
Practice Address - Phone:920-725-1566
Practice Address - Fax:920-725-8810
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2086152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38529500Medicaid
WIT87526Medicare UPIN