Provider Demographics
NPI:1871286153
Name:JOHANSON, GARY (LDO)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:JOHANSON
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 CORNERSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7174
Mailing Address - Country:US
Mailing Address - Phone:386-760-3330
Mailing Address - Fax:386-274-2051
Practice Address - Street 1:1460 CORNERSTONE BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7174
Practice Address - Country:US
Practice Address - Phone:386-760-3330
Practice Address - Fax:386-274-2051
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL01914156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician