Provider Demographics
NPI:1356348320
Name:DRIVER, ANTONIETTE JOHNSON (OD)
Entity type:Individual
Prefix:DR
First Name:ANTONIETTE
Middle Name:JOHNSON
Last Name:DRIVER
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:PO BOX 1045
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38351-1045
Mailing Address - Country:US
Mailing Address - Phone:731-968-1926
Mailing Address - Fax:731-968-1996
Practice Address - Street 1:1009 E CHURCH ST
Practice Address - Street 2:SUITE A
Practice Address - City:LEXINGTON
Practice Address - State:TN
Practice Address - Zip Code:38351-1947
Practice Address - Country:US
Practice Address - Phone:731-968-1926
Practice Address - Fax:731-968-1996
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2008-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD 1814152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3941512Medicaid
TN3154581OtherBLUE CROSS BLUE SHIELD
TN3154581OtherBLUE CROSS BLUE SHIELD
TN3892120001Medicare NSC
TN3941512Medicare PIN