Healthcare Provider Details

I. General information

NPI: 1497545289
Provider Name (Legal Business Name): MARILYN MARY JOHNSON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 MARTIN LUTHER KING BLVD
HOUSTON TX
77204-3069
US

IV. Provider business mailing address

2111 AUSTIN ST APT 412
HOUSTON TX
77002-8959
US

V. Phone/Fax

Practice location:
  • Phone: 713-743-2020
  • Fax:
Mailing address:
  • Phone: 231-598-1170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number11431TG
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11431
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: