Provider Demographics
NPI:1073784237
Name:CANYON, JOHN A (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:CANYON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75653-0337
Mailing Address - Country:US
Mailing Address - Phone:903-854-2192
Mailing Address - Fax:903-854-2407
Practice Address - Street 1:1400 LOWES BLVD
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-5201
Practice Address - Country:US
Practice Address - Phone:254-200-1165
Practice Address - Fax:254-634-1800
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02283152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT92165Medicare UPIN