Provider Demographics
NPI:1710166996
Name:MANDY O.D., P.C.
Entity Type:Organization
Organization Name:MANDY O.D., P.C.
Other - Org Name:OPTICAL GALLERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-234-9913
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 1:220 W 39TH ST
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-2802
Practice Address - Country:US
Practice Address - Phone:308-234-9913
Practice Address - Fax:308-234-4006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1220152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025556000Medicaid
37173OtherBCBS
NEDO7787Medicare PIN
NEV02048Medicare UPIN
37173OtherBCBS