Provider Demographics
NPI:1710031463
Name:JOHNSON, BRENT WARREN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:WARREN
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 1:700 SE CHKALOV DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-5202
Mailing Address - Country:US
Mailing Address - Phone:360-256-0612
Mailing Address - Fax:360-896-5503
Practice Address - Street 1:700 SE CHKALOV DR
Practice Address - Street 2:SUITE 5
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5202
Practice Address - Country:US
Practice Address - Phone:360-256-0612
Practice Address - Fax:360-896-5503
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2008-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1650TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2003523Medicaid
WATO1948Medicare UPIN
WA2003523Medicaid