Healthcare Provider Details

I. General information

NPI: 1801975826
Provider Name (Legal Business Name): ANDREW DANIEL JOHNSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 E LOHMAN AVE STE F
LAS CRUCES NM
88011-8256
US

IV. Provider business mailing address

3050 E LOHMAN AVE STE F
LAS CRUCES NM
88011-8256
US

V. Phone/Fax

Practice location:
  • Phone: 575-521-4053
  • Fax: 575-522-5592
Mailing address:
  • Phone: 575-521-4053
  • Fax: 575-522-5592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number544
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: