Provider Demographics
NPI:1063836096
Name:JOHNSON, BRYAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7202 GLEN FOREST DR STE 200
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3780
Mailing Address - Country:US
Mailing Address - Phone:804-673-2024
Mailing Address - Fax:804-673-1796
Practice Address - Street 1:10710 MIDLOTHIAN TPKE STE 138
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235
Practice Address - Country:US
Practice Address - Phone:804-348-2814
Practice Address - Fax:855-815-0304
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101258621208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC$$$$$$$$$OtherSSN