Provider Demographics
NPI:1790262137
Name:JOHNSON, BRYAN BRIGHT
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:BRIGHT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5003 HORIZONS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-5292
Mailing Address - Country:US
Mailing Address - Phone:614-224-1347
Mailing Address - Fax:614-224-5396
Practice Address - Street 1:5003 HORIZONS DR STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-5292
Practice Address - Country:US
Practice Address - Phone:614-224-1347
Practice Address - Fax:614-224-5396
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
OH2752696251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2752696Medicaid