Healthcare Provider Details

I. General information

NPI: 1235430216
Provider Name (Legal Business Name): GARY E. JOHNSON, O.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3757 55TH AVE S
FARGO ND
58104-6365
US

IV. Provider business mailing address

3757 55TH AVE S
FARGO ND
58104-6365
US

V. Phone/Fax

Practice location:
  • Phone: 701-356-1717
  • Fax: 701-356-1718
Mailing address:
  • Phone: 701-356-1717
  • Fax: 701-356-1718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number607
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. GARY ELIJAH JOHNSON
Title or Position: PRESIDENT
Credential: O.D.
Phone: 701-640-8773