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NPI Code Detail

MEDICARE: DR. ANDREW PUDJOWARGONO OD

MEDICARE: DR. ANDREW PUDJOWARGONO OD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist980NV

General Provider Information

NPI Number : 1285120311
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ANDREW PUDJOWARGONO OD
Provider Business Mailing Address
First Line : 46 PENMARRIC PLACE
Second Line :
City : TORONTO
State : ONTARIO
Zip : M1V4E6
Country : CA
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2021 N RAINBOW BLVD STE 100
Second Line :
City : LAS VEGAS
State : NV
Zip : 89108-7098
Country : US
Telephone Number : 702-452-2020
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/01/2018
Last Update Date : 07/01/2018

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