Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 152W00000X | Optometrist | 046.010370 | IL |
Y | 152W00000X | Optometrist | 2693 | AR |
NPI | 1013229442 |
---|---|
Provider Name | Jeffery Blake Johnson |
First Address | Pine Bluff, AR 71603 |
Second Address | Pine Bluff, AR 71603 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2010 |
Last Update Date | 07/03/2014 |