Provider Demographics
NPI:1790781896
Name:JOHNSON, BRIAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-635-5264
Mailing Address - Fax:573-556-5757
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-635-5264
Practice Address - Fax:573-761-4351
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108712207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO434227OtherHEALTHLINK IND
MO7034216OtherAETNA
MO127908OtherGROUP HEALTH PLAN
MO204961809Medicaid
MO128687OtherANTHEM BLUE CROSS BLUE SH
MO204961809OtherMO CARE IND
MO9201146OtherUNITED HEALTHCARE
MO1816637OtherFIRST HEALTH
MO20433OtherHEALTHCARE USA IND
MOA002OtherTRICARE IND
MOH12503OtherMERCY
MOP00119749OtherRAILROAD MEDICARE
MO204961809OtherMO CARE IND
MO002013291Medicare PIN