Provider Demographics
NPI:1033630330
Name:JOHNSON, BRIAN BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:BRADLEY
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 1:5630 LOWERY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-2233
Mailing Address - Country:US
Mailing Address - Phone:757-455-5009
Mailing Address - Fax:
Practice Address - Street 1:5630 LOWERY RD STE 200
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-2233
Practice Address - Country:US
Practice Address - Phone:757-455-5009
Practice Address - Fax:757-362-3577
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295178207N00000X
PAMD478832207N00000X
VA0101279110207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology