Provider Demographics
NPI:1619916137
Name:JOHNSON, BRADLEY AARON (OD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:AARON
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:PO BOX 2758
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2758
Mailing Address - Country:US
Mailing Address - Phone:319-234-2616
Mailing Address - Fax:319-234-1939
Practice Address - Street 1:909 E SAN MARNAN DRIVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5611
Practice Address - Country:US
Practice Address - Phone:319-234-2616
Practice Address - Fax:319-234-1939
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02255152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0417964Medicaid
IA35259OtherWELLMARK INS PLAN
IA421417307H4OtherJOHN DEERE HEALTH INS PLA
IA421417307H4OtherJOHN DEERE HEALTH INS PLA
IAI10222Medicare ID - Type Unspecified