Provider Demographics
NPI:1366654899
Name:JOHNSON, BRUCE GORDON (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:GORDON
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 1:839 ELMA STREET
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601
Mailing Address - Country:US
Mailing Address - Phone:307-377-6659
Mailing Address - Fax:
Practice Address - Street 1:2610 SOUTH DOUGLAS HIGHWAY
Practice Address - Street 2:SUITE 190
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718
Practice Address - Country:US
Practice Address - Phone:307-682-7861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY116T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist