Healthcare Provider Details

I. General information

NPI: 1295829380
Provider Name (Legal Business Name): CHARLOTTE OPTOMETRY GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 JW CLAY BLVD
CHARLOTTE NC
28262-5417
US

IV. Provider business mailing address

8701 JW CLAY BLVD
CHARLOTTE NC
28262-5417
US

V. Phone/Fax

Practice location:
  • Phone: 704-510-0816
  • Fax: 704-510-0919
Mailing address:
  • Phone: 704-510-0816
  • Fax: 704-510-0919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1458
License Number StateNC

VIII. Authorized Official

Name: DR. MICHAEL JAMES JOHNSON
Title or Position: VICE PRESIDENT
Credential: O.D.
Phone: 704-510-0816