Healthcare Provider Details

I. General information

NPI: 1184682312
Provider Name (Legal Business Name): MILLIE A JOHNSON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 E MAIN ST
BENSON NC
27504-1511
US

IV. Provider business mailing address

PO BOX 397
BENSON NC
27504-0397
US

V. Phone/Fax

Practice location:
  • Phone: 919-894-2001
  • Fax: 919-894-3190
Mailing address:
  • Phone: 919-894-2001
  • Fax: 919-894-3190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1327
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: