Healthcare Provider Details

I. General information

NPI: 1588680938
Provider Name (Legal Business Name): DR HEIDI JOHNSON OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 03/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2822 VENTURE DR
MARQUETTE MI
49855-8631
US

IV. Provider business mailing address

2822 VENTURE DR
MARQUETTE MI
49855-8631
US

V. Phone/Fax

Practice location:
  • Phone: 906-228-4401
  • Fax: 906-225-0460
Mailing address:
  • Phone: 906-228-4401
  • Fax: 906-225-0460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number StateGU
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateMI

VIII. Authorized Official

Name: HEIDI LEE JOHNSON
Title or Position: OWNER, OPTOMOTRIST
Credential: O.D., F.C.O.V.D.
Phone: 906-228-4401