Healthcare Provider Details

I. General information

NPI: 1356791545
Provider Name (Legal Business Name): SHANE M JOHNSTON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 S COUNTRY CLUB DR STE 102
MESA AZ
85210-6042
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 480-834-6367
  • Fax: 480-834-7277
Mailing address:
  • Phone: 703-847-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number2108
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2108
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: