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General NPI Number Information
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NPI Number | 1396190864
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Entity Type | Individual
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Provider Name | ALICIA MARIE JOHNSON O.D.
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Gender | Female
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Dates
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Enumeration Date | 05/03/2016
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Last Update Date | 05/03/2016
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Provider Practice Location Address
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Address Line | 32443 GRATIOT AVE
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City | ROSEVILLE
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State | MI
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Zip | 48066-1154
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Country | US
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Telephone | 586-415-0245
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Fax |
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Provider Business Mailing Address
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Address Line | 23172 REIN AVE
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City | EASTPOINTE
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State | MI
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Zip | 48021-4102
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Country | US
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Telephone | 248-657-3862
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4901004955
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License Number State | MI
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