1235239641 NPI number — DR. BRENT BUNDY JOHNSON OD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235239641 NPI number — DR. BRENT BUNDY JOHNSON OD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

JOHNSON

Provider First Name:

BRENT

Provider Middle Name:

BUNDY

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

OD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1235239641

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

10/26/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

5783 EAST LAKE RD

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ROMULUS

Provider Business Mailing Address State Name:

NY

Provider Business Mailing Address Postal Code:

14541

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

315-283-8928

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

714 HIGHWAY ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

MADISON

Provider Business Practice Location Address State Name:

NC

Provider Business Practice Location Address Postal Code:

27025-1508

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

336-427-2020

Provider Business Practice Location Address Fax Number:

336-427-2022

Provider Enumeration Date:

09/25/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 152W00000X , with the licence number:  OET 008758 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 152W00000X , with the licence number: TUV 006646 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 152W00000X , with the licence number: 1830 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 44324 . This is a "DAVIS (3221)" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 44944 . This is a "DAVIS (2528)" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 44945 . This is a "DAVIS (1945)" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 49273 . This is a "DAVIS (2992)" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 000926375001 . This is a "HEALTHNOW (3221)" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 46709 . This is a "SPECTERA (2992)" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 55760 . This is a "DAVIS (1976)" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: JO 1634168 . This is a "HIGHMARK (2992)" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 44519 . This is a "SPECTERA (1976)" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 000160882 . This is a "EXCELLUS (3221)" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 44281 . This is a "SPECTERA (1945)" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: JO 1368847 . This is a "PENN BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".