Provider Demographics
NPI:1558319707
Name:LETTS, JOHANNA E (OD)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:E
Last Name:LETTS
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 1:2002 MEDICAL PKWY
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3046
Mailing Address - Country:US
Mailing Address - Phone:410-571-8733
Mailing Address - Fax:410-571-6309
Practice Address - Street 1:2002 MEDICAL PKWY
Practice Address - Street 2:SUITE 320
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3046
Practice Address - Country:US
Practice Address - Phone:410-571-8733
Practice Address - Fax:410-571-6309
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1492152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD967L556EMedicare ID - Type Unspecified
MDU89322Medicare UPIN