Healthcare Provider Details

I. General information

NPI: 1699785410
Provider Name (Legal Business Name): KYLE DALE JOHNSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 E OHIO ST
CLINTON MO
64735-2458
US

IV. Provider business mailing address

1516 S 5TH ST E
LOUISBURG KS
66053-4186
US

V. Phone/Fax

Practice location:
  • Phone: 660-864-7116
  • Fax: 660-864-7124
Mailing address:
  • Phone: 913-244-8655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2003014755
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1687
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: