MEDICARE: ROBERT I 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	152WP0200X	Pediatric Optometrist	OPT2383	CO
2	152WS0006X	Sports Vision Optometrist	OPT2383	CO
3	152W00000X	Optometrist	OPT2383	CO
4	152WV0400X	Vision Therapy Optometrist	OPT2383	CO

General Provider Information

NPI Number	:	1982737607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT I JOHNSON O.D.

Provider Business Mailing Address
First Line	:	373 W DRAKE RD
Second Line	:	SUITE 3
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-2881
Country	:	US
Telephone Number	:	970-223-7150
Fax Number	:

Provider Business Practice Location Address
First Line	:	375 E HORSETOOTH RD BLDG 4
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3155
Country	:	US
Telephone Number	:	970-377-3111
Fax Number	:

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

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	06/27/2019

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