MEDICARE: DR MATTHEW JOHANNES OD, LLC

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
1	152W00000X	Optometrist	1552	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508274960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR MATTHEW JOHANNES OD, LLC

Provider Business Mailing Address
First Line	:	410 N CAMPUS DR
Second Line	:
City	:	GARDEN CITY
State	:	KS
Zip	:	67846-6134
Country	:	US
Telephone Number	:	620-275-2222
Fax Number	:	620-275-0829

Provider Business Practice Location Address
First Line	:	410 N CAMPUS DR
Second Line	:
City	:	GARDEN CITY
State	:	KS
Zip	:	67846-6134
Country	:	US
Telephone Number	:	620-275-2222
Fax Number	:	620-275-0829

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	MATTHEW JOHANNES
Credential	:	OD
Telephone Number	:	620-275-2222

Provider Enumeration Date	:	07/30/2014
Last Update Date	:	04/14/2020

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