Provider Demographics
NPI:1902901713
Name:SCHWICHTENBERG, ANDREW R (OD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:R
Last Name:SCHWICHTENBERG
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 1:2829 E OAKLAND AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1347
Mailing Address - Country:US
Mailing Address - Phone:423-283-4590
Mailing Address - Fax:423-283-0867
Practice Address - Street 1:2829 E OAKLAND AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1347
Practice Address - Country:US
Practice Address - Phone:423-283-4590
Practice Address - Fax:423-283-0867
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1154152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DT7841Medicare PIN
TN3596626Medicare ID - Type UnspecifiedPARTICIPATING PROVIDER ID
TNT61328Medicare UPIN
TN0138990001Medicare NSC
410028934Medicare PIN