Provider Demographics
NPI:1407865660
Name:JOHNSON, BRIAN DAVID (PHD, NP)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 N MIRA LOMA WAY
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-2977
Mailing Address - Country:US
Mailing Address - Phone:310-989-5654
Mailing Address - Fax:
Practice Address - Street 1:1836 N MIRA LOMA WAY
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-2977
Practice Address - Country:US
Practice Address - Phone:310-989-5654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13975103TC0700X
CANP22980363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR74047Medicare UPIN
CACA209618Medicare PIN
CACA209618Medicare PIN
CACP13975DMedicare PIN