Provider Demographics
NPI:1538130844
Name:JOHNSON, BRADLEY D (DO)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3366 OAKDALE AVE N
Mailing Address - Street 2:150
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2948
Mailing Address - Country:US
Mailing Address - Phone:763-520-7840
Mailing Address - Fax:763-520-1578
Practice Address - Street 1:3366 OAKDALE AVE N
Practice Address - Street 2:150
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2948
Practice Address - Country:US
Practice Address - Phone:763-520-7840
Practice Address - Fax:763-520-1578
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN45555174400000X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN323630700Medicaid
MNH94294Medicare UPIN