=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699757039
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAX SNITKER JOHNSON OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2005
-----------------------------------------------------
Last Update Date | 05/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 N DELAWARE AVE
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88203-3042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-624-0235
-----------------------------------------------------
Fax | 575-624-0236
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 N DELAWARE AVE
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88203-3042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-624-0235
-----------------------------------------------------
Fax | 575-624-0236
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 267
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------