Provider Demographics
NPI:1841307733
Name:JOHN TODD CORNETTOD PA
Entity type:Organization
Organization Name:JOHN TODD CORNETTOD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN TODD
Authorized Official - Middle Name:P
Authorized Official - Last Name:CORNETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD PA
Authorized Official - Phone:806-356-6868
Mailing Address - Street 1:3635 SONCY
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119
Mailing Address - Country:US
Mailing Address - Phone:806-368-6868
Mailing Address - Fax:806-351-0120
Practice Address - Street 1:3635 SONCY
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119
Practice Address - Country:US
Practice Address - Phone:806-368-6868
Practice Address - Fax:806-351-0120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4625TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDG014OtherRAILROAD
TX0071PWOtherBCBS
TX019422701Medicaid
TX019422701Medicaid
TX00W943Medicare PIN