Provider Demographics
NPI:1194774174
Name:JOHNSON, BRENDON J (OD)
Entity type:Individual
Prefix:
First Name:BRENDON
Middle Name:J
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 1:2611 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-2501
Mailing Address - Country:US
Mailing Address - Phone:309-347-5989
Mailing Address - Fax:309-347-4315
Practice Address - Street 1:2611 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-2501
Practice Address - Country:US
Practice Address - Phone:309-347-5989
Practice Address - Fax:309-347-4315
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009489152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09032051OtherBLUE CROSS/SHIELD OF IL
IL046009489Medicaid
IL563081OtherHEALTHLINK
IL209352/K07764Medicare ID - Type Unspecified
IL046009489Medicaid
IL5428040001Medicare NSC