Healthcare Provider Details

I. General information

NPI: 1437012671
Provider Name (Legal Business Name): KODY JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9624 US HIGHWAY 19
PORT RICHEY FL
34668-4642
US

IV. Provider business mailing address

1185 S PINELLAS AVE APT 5203
TARPON SPRINGS FL
34689-3761
US

V. Phone/Fax

Practice location:
  • Phone: 727-232-2949
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6974
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: