Provider Demographics
NPI:1679550933
Name:JOHNSON, BRENT MITCHELL (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:MITCHELL
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 1:2331 FRANKLIN RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-1111
Mailing Address - Country:US
Mailing Address - Phone:540-725-1226
Mailing Address - Fax:540-857-5306
Practice Address - Street 1:2331 FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1111
Practice Address - Country:US
Practice Address - Phone:540-725-1226
Practice Address - Fax:540-857-5306
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043592207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1679550933OtherAETNA
VA1679550933OtherUMWA
VA1679550933Medicaid
VA3810018723OtherMEDICAID OF WEST VIRGINIA
VAP00831109OtherRAILROAD MEDICARE
VA1679550933OtherSOUTHERN HEALTH/CARENET/CARELINK/COVENTRY
VA540506332005OtherTRICARE/CHAMPUS
VA1679550933OtherANTHEM
VA1679550933OtherCIGNA
VA1679550933OtherHUMANA MEDICARE
VA1679550933OtherVIRGINIA HEALTH NETWORK
VA1679550933OtherHEALTHKEEPERS
VA1679550933OtherMEDICAID OF NORTH CAROLINA
VA1679550933OtherVA PREMIER
VA1679550933OtherHEALTHKEEPERS PLUS
VA1679550933OtherGATEWAY
VA1679550933OtherOPTIMA HEALTH PLAN
VA1679550933OtherUNITED HEALTHCARE
VA371194700OtherBLACK LUNG
VA1679550933OtherINTOTAL
VA1679550933OtherUNITED HEALTHCARE
VA371194700OtherBLACK LUNG
C70482Medicare UPIN