Provider Demographics
NPI:1629014626
Name:JOHNSON, JON BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:BRADLEY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:130 DESIARD ST
Mailing Address - Street 2:SUITE 355
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7319
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-6603
Practice Address - Street 1:2516 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2988
Practice Address - Country:US
Practice Address - Phone:318-387-9420
Practice Address - Fax:318-323-8216
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA021605208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1698326Medicaid
LA331446YJBUMedicare PIN
LA1698326Medicaid
LA5Y603Medicare PIN