Provider Demographics
NPI:1912934035
Name:JOHNSON, BRYAN L (OD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:L
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 1:698 WESTSIDE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-3085
Mailing Address - Country:US
Mailing Address - Phone:580-795-4447
Mailing Address - Fax:
Practice Address - Street 1:698 WESTSIDE DR
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3084
Practice Address - Country:US
Practice Address - Phone:580-795-4447
Practice Address - Fax:580-371-2122
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2103152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100765110AMedicaid
OK100759890AMedicaid
OK100765110AMedicaid
OK100759890AMedicaid
OK100765110AMedicaid