=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497545289
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARILYN MARY JOHNSON OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2025
-----------------------------------------------------
Last Update Date | 07/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4401 MARTIN LUTHER KING BLVD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77204-3069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-743-2020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2111 AUSTIN ST APT 412
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77002-8959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-598-1170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WL0500X
-----------------------------------------------------
Taxonomy Name | Low Vision Rehabilitation Optometrist
-----------------------------------------------------
License Number | 11431TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 11431
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------