Provider Demographics
NPI:1740594159
Name:KETCHER, JOHN MAGNUS (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MAGNUS
Last Name:KETCHER
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:1424 E FRONT ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702
Practice Address - Country:US
Practice Address - Phone:903-595-4144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2022152W00000X
VA0618002629152W00000X
TX9394152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX393764101Medicaid
TXP02184376OtherMEDICARE RAIL ROAD