Provider Demographics
NPI:1043472327
Name:JOHNSON, KATHLEEN ANN (OD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 HEMPSTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11552-2043
Mailing Address - Country:US
Mailing Address - Phone:516-565-2616
Mailing Address - Fax:516-481-1953
Practice Address - Street 1:320 HEMPSTEAD AVE
Practice Address - Street 2:
Practice Address - City:W HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552-2043
Practice Address - Country:US
Practice Address - Phone:516-565-2616
Practice Address - Fax:516-481-1953
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007279-01152W00000X
NYTUV007279152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist