Provider Demographics
NPI:1679539274
Name:JOHNSON, MANDY JANE (OD)
Entity Type:Individual
Prefix:DR
First Name:MANDY
Middle Name:JANE
Last Name:JOHNSON
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 1:5403 N AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-8514
Mailing Address - Country:US
Mailing Address - Phone:308-234-9133
Mailing Address - Fax:308-234-4006
Practice Address - Street 1:5403 N AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-8514
Practice Address - Country:US
Practice Address - Phone:308-234-9133
Practice Address - Fax:308-234-4006
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1220152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V02048Medicare UPIN
NE278106Medicare PIN
NEP00705933Medicare PIN