MEDICARE: BRENT DANIEL JOHNSON OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2195	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689667875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT DANIEL JOHNSON OD

Provider Business Mailing Address
First Line	:	PO BOX 36
Second Line	:
City	:	BLUE EARTH
State	:	MN
Zip	:	56013-0036
Country	:	US
Telephone Number	:	507-526-2222
Fax Number	:	507-526-3927

Provider Business Practice Location Address
First Line	:	435 S GROVE ST
Second Line	:	SUITE 2
City	:	BLUE EARTH
State	:	MN
Zip	:	56013-2604
Country	:	US
Telephone Number	:	507-526-2222
Fax Number	:	507-526-3927

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	02/08/2013

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