Provider Demographics
NPI:1730198714
Name:JOHNSON, SANDRA MARIE (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-1506
Practice Address - Fax:573-884-5575
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME133380207W00000X, 207WX0009X, 207W00000X
MO2020032290207W00000X, 207WX0009X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021901500Medicaid
FLRU935OtherBLUE CROSS BLUE SHIELD
VT1009997Medicaid
FL021901500Medicaid
F78634Medicare UPIN
NHRE7371Medicare ID - Type Unspecified