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General NPI Number Information
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NPI Number | 1831107986
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Entity Type | Individual
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Provider Name | MACK WRAY JOHNSON O.D.
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Gender | Male
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Dates
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Enumeration Date | 08/04/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 301 NORTHRIDGE CIR
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City | GUYMON
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State | OK
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Zip | 73942-2735
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Country | US
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Telephone | 580-338-8437
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Fax | 580-338-8361
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Provider Business Mailing Address
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Address Line | 301 NORTHRIDGE CIR
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City | GUYMON
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State | OK
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Zip | 73942-2735
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Country | US
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Telephone | 580-338-8437
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Fax | 580-338-8361
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2159
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License Number State | OK
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