Healthcare Provider Details

I. General information

NPI: 1225000540
Provider Name (Legal Business Name): WARREN S JOHNSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 PERKINS EXT
MEMPHIS TN
38117
US

IV. Provider business mailing address

428 PERKINS EXT
MEMPHIS TN
38117-3802
US

V. Phone/Fax

Practice location:
  • Phone: 901-763-2020
  • Fax: 901-763-2219
Mailing address:
  • Phone: 901-763-2020
  • Fax: 901-763-2219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODT968
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberODT968
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: