Provider Demographics
NPI:1467514646
Name:MAHONEY, JOHN TODD (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TODD
Last Name:MAHONEY
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 1:3726 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4665
Mailing Address - Country:US
Mailing Address - Phone:308-635-1234
Mailing Address - Fax:308-635-7505
Practice Address - Street 1:3726 AVENUE D
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4665
Practice Address - Country:US
Practice Address - Phone:308-635-1234
Practice Address - Fax:308-635-7505
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY174T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY103472300Medicaid
WY410017084OtherRR MEDICARE PROVIDER NUMB
WY310524OtherBCBS PROVIDER NUMBER
WYT71358Medicare UPIN
WY0312350002Medicare NSC
WY103472300Medicaid
WYW4591089Medicare PIN