Provider Demographics
NPI:1508923731
Name:JOHNSON, SHANE (OD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:STE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6803
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:5403 W 88TH AVE
Practice Address - Street 2:SP #45
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-3084
Practice Address - Country:US
Practice Address - Phone:303-428-1220
Practice Address - Fax:303-657-8689
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2262152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU88283Medicare UPIN