Provider Demographics
NPI:1285120311
Name:PUDJOWARGONO, ANDREW (OD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:PUDJOWARGONO
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 1:46 PENMARRIC PLACE
Mailing Address - Street 2:
Mailing Address - City:TORONTO
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:M1V4E6
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2021 N RAINBOW BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-7098
Practice Address - Country:US
Practice Address - Phone:702-452-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-01
Last Update Date:2018-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV980152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist