Provider Demographics
NPI:1578556189
Name:JOHNSON, BRIAN T (MD PL)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD PL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1805 CYPRESS BROOK DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4417
Mailing Address - Country:US
Mailing Address - Phone:727-264-8833
Mailing Address - Fax:727-264-8827
Practice Address - Street 1:1805 CYPRESS BROOK DR
Practice Address - Street 2:SUITE 101
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4417
Practice Address - Country:US
Practice Address - Phone:727-264-8833
Practice Address - Fax:727-264-8827
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0057286207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2372307OtherGHI
FLP01014397OtherRAILROAD MEDICARE
FL002WHOtherBLUE CROSS/BLUE SHIELD FLORIDA GROUP ID#
FL10230OtherBLUE CROSS/BLUE SHIELD FLORIDA ID#
FLP00181819OtherRAILROAD MEDICARE
DC6458OtherPROV AND GROUP #
FLDS2914OtherPROV AND GROUP #
FL002WHOtherBLUE CROSS/BLUE SHIELD FLORIDA GROUP ID#
FL10230OtherBLUE CROSS/BLUE SHIELD FLORIDA ID#
FLDS2914OtherPROV AND GROUP #