Provider Demographics
NPI:1134116684
Name:JOHNSON, BRADLEY W (DO)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 W CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-1844
Mailing Address - Country:US
Mailing Address - Phone:563-421-4400
Mailing Address - Fax:563-421-4449
Practice Address - Street 1:1345 W CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1844
Practice Address - Country:US
Practice Address - Phone:563-421-4400
Practice Address - Fax:563-421-4449
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA4136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine