Provider Demographics
NPI:1164495115
Name:JOHNSON, BRIAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:L
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
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:757-362-3577
Practice Address - Street 1:5630 LOWERY RD
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:2006-02-09
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048364207N00000X, 207ND0101X, 207ND0900X, 207NI0002X, 208D00000X, 207NS0135X
VA0101042937207N00000X, 207ND0101X, 207N00000X
GA049364207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA528051176Medicaid
GA07BBSSJMedicare PIN