Provider Demographics
NPI:1174509442
Name:BRIAN, JOHNNY EDWARD JR (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:EDWARD
Last Name:BRIAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 2441
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52809-2441
Mailing Address - Country:US
Mailing Address - Phone:563-324-8160
Mailing Address - Fax:563-324-8486
Practice Address - Street 1:1227 E RUSHOLME ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2498
Practice Address - Country:US
Practice Address - Phone:563-421-1000
Practice Address - Fax:563-421-7889
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IA29071207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1093203Medicaid
C67873Medicare UPIN
IA1093203Medicaid