Provider Demographics
NPI:1487640447
Name:JOHNSON, BRENT E (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:E
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 1:1000 AINSWORTH DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1667
Mailing Address - Country:US
Mailing Address - Phone:928-778-1971
Mailing Address - Fax:928-443-8473
Practice Address - Street 1:1000 AINSWORTH DR
Practice Address - Street 2:SUITE 115
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1667
Practice Address - Country:US
Practice Address - Phone:928-778-1971
Practice Address - Fax:928-443-8473
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20366174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ069709Medicaid
Z76089Medicare PIN
F07709Medicare UPIN
AZ069709Medicaid