Healthcare Provider Details

I. General information

NPI: 1184700825
Provider Name (Legal Business Name): JOHNSON EYE CLINIC, P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 10TH ST
WORTHINGTON MN
56187-2767
US

IV. Provider business mailing address

702 10TH ST PO BOX 726
WORTHINGTON MN
56187-2767
US

V. Phone/Fax

Practice location:
  • Phone: 507-376-5535
  • Fax: 507-376-4805
Mailing address:
  • Phone: 507-376-5535
  • Fax: 507-376-4805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: WALLACE S JOHNSON
Title or Position: CHIEF FINANCIAL OFFICER
Credential: O.D.
Phone: 507-376-5535