Provider Demographics
NPI:1114971223
Name:JOHNSTON, BRAD M (MD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:M
Last Name:JOHNSTON
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 1:3707 NEW VISION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1702
Mailing Address - Country:US
Mailing Address - Phone:260-969-1124
Mailing Address - Fax:614-210-1886
Practice Address - Street 1:3707 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46895-5602
Practice Address - Country:US
Practice Address - Phone:260-471-9466
Practice Address - Fax:260-484-5919
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056073A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200491720Medicaid
IN000000362157OtherANTHEM
IN925240CCMedicare ID - Type Unspecified
IN194930WMedicare ID - Type Unspecified
INI18643Medicare UPIN
IN163520YMedicare ID - Type Unspecified
IN190320WMedicare ID - Type Unspecified
IN191150XMedicare ID - Type Unspecified
IN147380ZMedicare ID - Type Unspecified
IN000000362157OtherANTHEM
INP00257254Medicare ID - Type Unspecified
IN055740CCMedicare ID - Type Unspecified