Provider Demographics
NPI:1770063687
Name:JOHNSON, BRIAN (OD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
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 1:3509 SILVERSIDE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4903
Mailing Address - Country:US
Mailing Address - Phone:302-477-2621
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:3509 SILVERSIDE RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4903
Practice Address - Country:US
Practice Address - Phone:302-477-2608
Practice Address - Fax:302-477-2654
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEI3-0011449152W00000X
PAOEG003474152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOEG003474OtherLICENSE