Individual
JOHN MAGNUS KETCHER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
1424 E FRONT ST, TYLER, TX 75702
(903) 595-4144
Mailing address
PO BOX 846098, DALLAS, TX 75284-6098
(903) 324-6400
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
0618002629
VA
152W00000X
Optometrist
2022
AZ
152W00000X
Optometrist
Primary
9394
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
393764101
—
TX
01
—
P02184376
MEDICARE RAIL ROAD
TX
Enumeration date
07/28/2010
Last updated
05/17/2019
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