Healthcare Provider Details

I. General information

NPI: 1184608200
Provider Name (Legal Business Name): BRYAN LOWELL JOHNSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 05/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 11TH AVE NW
ROCHESTER MN
55901-4276
US

IV. Provider business mailing address

3630 11TH AVE NW
ROCHESTER MN
55901-4276
US

V. Phone/Fax

Practice location:
  • Phone: 507-288-2457
  • Fax: 507-288-1299
Mailing address:
  • Phone: 507-288-2457
  • Fax: 507-288-1299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2090
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: