=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528113669
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHARON LARUTH JOHNSON O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | BLDG. 33003, BATALLION AVE. MONROE TROOP MEDICAL CLINIC
-----------------------------------------------------
City | FORT HOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76544-4752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-288-5087
-----------------------------------------------------
Fax | 254-287-3534
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4205 TIMBER TRAIL CT
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76016-4623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-996-2881
-----------------------------------------------------
Fax | 817-561-6474
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4666TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------