Provider Demographics
NPI:1922036813
Name:JOHNSON, BRYAN RAYMOND (OD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:RAYMOND
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 1:432 W. UNIVERSITY DR.
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307
Mailing Address - Country:US
Mailing Address - Phone:248-651-6122
Mailing Address - Fax:
Practice Address - Street 1:432 W. UNIVERSITY DR.
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307
Practice Address - Country:US
Practice Address - Phone:248-651-6122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U04640Medicare UPIN
F36287002Medicare PIN