Provider Demographics
NPI:1699757039
Name:JOHNSON, MAX SNITKER (OD)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:SNITKER
Last Name:JOHNSON
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 1:106 N DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-3042
Mailing Address - Country:US
Mailing Address - Phone:575-624-0235
Mailing Address - Fax:575-624-0236
Practice Address - Street 1:106 N DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-3042
Practice Address - Country:US
Practice Address - Phone:575-624-0235
Practice Address - Fax:575-624-0236
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM267152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP0458Medicaid
NMT74976Medicare UPIN
NM2591308Medicare PIN