Provider Demographics
NPI:1235429150
Name:ANDREW D. JOHNSON, O.D., P.C.
Entity Type:Organization
Organization Name:ANDREW D. JOHNSON, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:575-625-2020
Mailing Address - Street 1:4500 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-0305
Mailing Address - Country:US
Mailing Address - Phone:575-625-2020
Mailing Address - Fax:505-622-7816
Practice Address - Street 1:4500 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-0305
Practice Address - Country:US
Practice Address - Phone:575-625-2020
Practice Address - Fax:505-622-7816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM0544305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service