=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154345486
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC J JOHNSON II O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 05/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 20TH AVE
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39301-4121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-485-2368
-----------------------------------------------------
Fax | 601-693-2174
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1551
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39302-1551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-485-2368
-----------------------------------------------------
Fax | 601-693-2174
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 684
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------