MEDICARE: DR. SAMANTHA MICHELLE JOHNSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	33472	CA

General Provider Information

NPI Number	:	1144774928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMANTHA MICHELLE JOHNSON O.D.

Provider Business Mailing Address
First Line	:	8640 GULANA AVE UNIT J2016
Second Line	:
City	:	PLAYA DEL REY
State	:	CA
Zip	:	90293-7321
Country	:	US
Telephone Number	:	619-820-2756
Fax Number	:

Provider Business Practice Location Address
First Line	:	4545 E 3RD ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90022-1656
Country	:	US
Telephone Number	:	323-261-3098
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2016
Last Update Date	:	08/24/2022

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