Provider Demographics
NPI:1114078771
Name:JOHANNSEN, ANN M (OD)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:M
Last Name:JOHANNSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-3490
Mailing Address - Country:US
Mailing Address - Phone:909-625-7861
Mailing Address - Fax:909-621-0742
Practice Address - Street 1:695 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-3490
Practice Address - Country:US
Practice Address - Phone:909-625-7861
Practice Address - Fax:909-621-0742
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7500T152WC0802X, 152W00000X, 152WP0200X
CAWOP7500TPG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WOP7500AOtherMEDICARE PTAN
CA0849310002Medicare NSC
CAWY040Medicare UPIN
CAWY040Medicare PIN
CAU34034Medicare UPIN