Provider Demographics
NPI:1730344433
Name:JOHNSON, DALE S (OD)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:S
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 1:983 W STATE ROAD 434
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5103
Mailing Address - Country:US
Mailing Address - Phone:407-261-0505
Mailing Address - Fax:407-831-4936
Practice Address - Street 1:983 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5103
Practice Address - Country:US
Practice Address - Phone:407-261-0505
Practice Address - Fax:407-831-4936
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2675152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65054OtherPREMIER EYECARE
FL621271900Medicaid
FL20497ZMedicare PIN
FLUPIN U50352Medicare UPIN