Provider Demographics
NPI:1578523866
Name:JOHNSON, BRUCE EVAN (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:EVAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:450 BROOKLINE AVE
Mailing Address - Street 2:D1234 DANA-FARBER CANCER INSTITUTE
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5418
Mailing Address - Country:US
Mailing Address - Phone:617-632-4790
Mailing Address - Fax:617-632-5786
Practice Address - Street 1:450 BROOKLINE AVE
Practice Address - Street 2:DANA-FARBER CANCER INSTITUTE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5418
Practice Address - Country:US
Practice Address - Phone:617-632-4790
Practice Address - Fax:617-632-5786
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA158661207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ19701OtherBCBS INDEMITY BC ELECT HM
2172993OtherAETNA US HEALTHCARE
45879OtherFALLON COMMUNITY HEALTH P
3185516OtherMASSHEALTH MA MEDICAID
5876473OtherCIGNA
3000439OtherUNITED HEALTH CARE
158661OtherTUFTS
68815DFOtherHPHC DFCI ONLY
A29168Medicare ID - Type Unspecified
68815DFOtherHPHC DFCI ONLY