Provider Demographics
NPI:1689667875
Name:JOHNSON, BRENT DANIEL (OD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:DANIEL
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 36
Mailing Address - Street 2:
Mailing Address - City:BLUE EARTH
Mailing Address - State:MN
Mailing Address - Zip Code:56013-0036
Mailing Address - Country:US
Mailing Address - Phone:507-526-2222
Mailing Address - Fax:507-526-3927
Practice Address - Street 1:435 S GROVE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BLUE EARTH
Practice Address - State:MN
Practice Address - Zip Code:56013-2604
Practice Address - Country:US
Practice Address - Phone:507-526-2222
Practice Address - Fax:507-526-3927
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2195152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN060225600Medicaid
MN060225600Medicaid
MN410001038Medicare ID - Type Unspecified