Provider Demographics
NPI:1255423307
Name:JOHNSON, CYNTHIA RUTH (OD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:RUTH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:RUTH
Other - Last Name:KINNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4265 FALLON ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-6756
Mailing Address - Country:US
Mailing Address - Phone:406-587-0668
Mailing Address - Fax:406-587-0396
Practice Address - Street 1:4265 FALLON ST,
Practice Address - Street 2:SUITE 1
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718
Practice Address - Country:US
Practice Address - Phone:406-587-0668
Practice Address - Fax:406-587-0396
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT530152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0480318Medicaid
MT0480318Medicaid
MT25126Medicare ID - Type Unspecified