| National Provider Identifier [NPI]: | 1598028201 |
| Last Name Of The Provider | JOHANSEN |
| First Name Of The Provider | ERIC |
| Middle Initial Of The Provider | D |
| Credentials Of The Provider | O.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 516 E. NIZHONI BLVD. |
| Street Address 2 Of The Provider | |
| City Of The Provider | GALLUP |
| Zip Code Of The Provider | 873011337 |
| State Code Of The Provider | NM |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Optometry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 17 |
| Number Of Services | 594 |
| Number Of Medicare Beneficiaries | 464 |
| Total Submitted Charge Amount | 63635 |
| Total Medicare Allowed Amount | 61443.4 |
| Total Medicare Payment Amount | 36408.77 |
| Total Medicare Standardized Payment Amount | 39816.01 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 17 |
| Number Of Medical Services | 594 |
| Number Of Medicare Beneficiaries With Medical Services | 464 |
| Total Medical Submitted Charge Amount | 63635 |
| Total Medical Medicare Allowed Amount | 61443.4 |
| Total Medical Medicare Payment Amount | 36408.77 |
| Total Medical Medicare Standardized Payment Amount | 39816.01 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 22 |
| Number Of Beneficiaries Age 65 to 74 | 239 |
| Number Of Beneficiaries Age 75 to 84 | 157 |
| Number Of Beneficiaries Age Greater 84 | 46 |
| Number Of Female Beneficiaries | 277 |
| Number Of Male Beneficiaries | 187 |
| Number Of Non Hispanic White Beneficiaries | 401 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 31 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 19 |
| Number Of Beneficiaries With Medicare Only Entitlement | 431 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 33 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 6 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 9 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 16 |
| Percent Of With Diabetes | 24 |
| Percent Of With Hyperlipidemia | 48 |
| Percent Of With Hypertension | 56 |
| Percent Of With Ischemic Heart Disease | 25 |
| Percent Of With Osteoporosis | 5 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 30 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 3 |
| Average HCC Risk Score Of Beneficiaries | 0.8626 |