Basic Information
| Provider Information | |||||||||
| NPI: | 1235239641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | BUNDY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5783 EAST LAKE RD | ||||||||
| Address2: | |||||||||
| City: | ROMULUS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152838928 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3354 W FRIENDLY AVE | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274104888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363870930 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OET 008758 | PA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | TUV 006646 | NY | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 1830 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 44944 | 01 | PA | DAVIS (2528) | OTHER | 44324 | 01 | NY | DAVIS (3221) | OTHER | JO 1368847 | 01 | PA | PENN BLUE SHIELD | OTHER | 46709 | 01 | NY | SPECTERA (2992) | OTHER | JO 1634168 | 01 | NY | HIGHMARK (2992) | OTHER | 000160882 | 01 | NY | EXCELLUS (3221) | OTHER | 44281 | 01 | PA | SPECTERA (1945) | OTHER | 44945 | 01 | PA | DAVIS (1945) | OTHER | 49273 | 01 | NY | DAVIS (2992) | OTHER | 000926375001 | 01 | NY | HEALTHNOW (3221) | OTHER | 44519 | 01 | NY | SPECTERA (1976) | OTHER | 55760 | 01 | NY | DAVIS (1976) | OTHER |