Provider Demographics
NPI:1558317370
Name:JOHNSON, BRIAN LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LEE
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:PO BOX 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3418
Mailing Address - Fax:415-883-8082
Practice Address - Street 1:1783 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3205
Practice Address - Country:US
Practice Address - Phone:650-696-5515
Practice Address - Fax:650-696-5280
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG357252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G357250Medicaid
CA30090772OtherRAILROAD MEDICARE
CA30090772OtherRAILROAD MEDICARE
CA00G357252Medicare PIN
CA00G357253Medicare PIN
CA00G357250Medicaid
CAA46453Medicare UPIN