Provider Demographics
NPI:1023012754
Name:JOHNSON, BRIAN ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:WINAMAC
Mailing Address - State:IN
Mailing Address - Zip Code:46996-1111
Mailing Address - Country:US
Mailing Address - Phone:574-946-6644
Mailing Address - Fax:574-946-7801
Practice Address - Street 1:613 TERRACE DR
Practice Address - Street 2:
Practice Address - City:WINAMAC
Practice Address - State:IN
Practice Address - Zip Code:46996-1111
Practice Address - Country:US
Practice Address - Phone:574-946-6644
Practice Address - Fax:574-946-7801
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100210710AMedicaid
670630AMedicare ID - Type Unspecified