=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194774174
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDON J JOHNSON O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2006
-----------------------------------------------------
Last Update Date | 12/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2611 BROADWAY ST
-----------------------------------------------------
City | PEKIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61554-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-347-5989
-----------------------------------------------------
Fax | 309-347-4315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2611 BROADWAY ST
-----------------------------------------------------
City | PEKIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61554-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-347-5989
-----------------------------------------------------
Fax | 309-347-4315
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046009489
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------