Provider Demographics
NPI:1639257207
Name:JOHNSON, BRANDI M (DPM)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 BUCKINGHAM PL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4910
Mailing Address - Country:US
Mailing Address - Phone:813-571-2977
Mailing Address - Fax:813-654-9545
Practice Address - Street 1:206 BUCKINGHAM PL
Practice Address - Street 2:SUITE 101
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4910
Practice Address - Country:US
Practice Address - Phone:813-571-2977
Practice Address - Fax:813-654-9545
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3199213ES0103X, 213E00000X, 213ES0131X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL202703OtherAMERIGROUP
FL65891OtherBCBS
FLPO3199OtherLICENSE NO
FL340534600Medicaid
FLP00420517OtherRAILROAD MEDICARE
FL340534600Medicaid
FLPO3199OtherLICENSE NO
FLV05251Medicare UPIN