Provider Demographics
NPI:1184608200
Name:JOHNSON, BRYAN LOWELL (OD)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:LOWELL
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 1:3630 11TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-4276
Mailing Address - Country:US
Mailing Address - Phone:507-288-2457
Mailing Address - Fax:507-288-1299
Practice Address - Street 1:3630 11TH AVE NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-4276
Practice Address - Country:US
Practice Address - Phone:507-288-2457
Practice Address - Fax:507-288-1299
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP44093OtherHEALTH PARTNERS
2201134OtherMEDICA CHOICE SELECT
MN4C934J0OtherBCBS OF MN
MN549823700Medicaid
01017733OtherPREFERRED ONE
MN4C934J0OtherBCBS OF MN
T88909Medicare UPIN
MN1225850001Medicare NSC