Provider Demographics
NPI:1740229749
Name:JOHNSON, BRENDA L (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 MAIN ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-1961
Mailing Address - Country:US
Mailing Address - Phone:781-729-5651
Mailing Address - Fax:781-729-8523
Practice Address - Street 1:955 MAIN ST
Practice Address - Street 2:SUITE 304
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-1961
Practice Address - Country:US
Practice Address - Phone:781-729-5651
Practice Address - Fax:781-729-8523
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA80366207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3185117Medicaid
J31050Medicare PIN
MA3185117Medicaid