Healthcare Provider Details

I. General information

NPI: 1245226976
Provider Name (Legal Business Name): MICHAEL EDWARD JOHNSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 N MAIN ST
LEEDS MA
01053-9764
US

IV. Provider business mailing address

605 LAFAYETTE RD
PORTSMOUTH NH
03801-5406
US

V. Phone/Fax

Practice location:
  • Phone: 413-345-1096
  • Fax:
Mailing address:
  • Phone: 603-629-0090
  • Fax: 603-629-0092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0762
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: