Provider Demographics
NPI:1487761748
Name:JOHNSON, BRIAN S (OD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:S
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:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:6695 W RIO GRANDE AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-3301
Practice Address - Country:US
Practice Address - Phone:509-736-0826
Practice Address - Fax:509-735-6868
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003721152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1487761748Medicaid
NM33287775Medicaid
ID410048907OtherRAIL ROAD MEDICARE
WA410047918OtherRAIL ROAD MEDICARE
WA1011663Medicaid
WA410047917OtherRAIL ROAD MEDICARE
U90439Medicare UPIN
WAGAB29277Medicare PIN
WAGAB29279Medicare PIN
WAGAB29278Medicare PIN
WAGAB29274Medicare PIN