Provider Demographics
NPI:1235239641
Name:JOHNSON, BRENT BUNDY (OD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:BUNDY
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 1:5783 EAST LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:NY
Mailing Address - Zip Code:14541
Mailing Address - Country:US
Mailing Address - Phone:315-283-8928
Mailing Address - Fax:
Practice Address - Street 1:714 HIGHWAY ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:NC
Practice Address - Zip Code:27025-1508
Practice Address - Country:US
Practice Address - Phone:336-427-2020
Practice Address - Fax:336-427-2022
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOET 008758152W00000X
NYTUV 006646152W00000X
NC1830152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY44324OtherDAVIS (3221)
PA44944OtherDAVIS (2528)
PA44945OtherDAVIS (1945)
NY49273OtherDAVIS (2992)
NY000926375001OtherHEALTHNOW (3221)
NY46709OtherSPECTERA (2992)
NY55760OtherDAVIS (1976)
NYJO 1634168OtherHIGHMARK (2992)
NY44519OtherSPECTERA (1976)
NY000160882OtherEXCELLUS (3221)
PA44281OtherSPECTERA (1945)
PAJO 1368847OtherPENN BLUE SHIELD
PAJO 1368847OtherPENN BLUE SHIELD
PA44944OtherDAVIS (2528)
NYVO1022Medicare UPIN