Provider Demographics
NPI:1336109495
Name:JOHNSON, BRUCE M (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:M
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 1:2602 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19013-2040
Mailing Address - Country:US
Mailing Address - Phone:610-497-7548
Mailing Address - Fax:610-497-7487
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19013-3902
Practice Address - Country:US
Practice Address - Phone:610-874-5257
Practice Address - Fax:610-874-7241
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA057520002084P0800X
PAMD4375072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ556046TB1Medicare ID - Type Unspecified
NJC10777Medicare UPIN