Provider Demographics
NPI:1295899763
Name:JOHNSON, BRENDA CAMILLE (MD)
Entity type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:CAMILLE
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:US HWY 160 & NAVAJO RT 35
Mailing Address - Street 2:HCR 6100 BOX 30
Mailing Address - City:TEEC NOS POS
Mailing Address - State:AZ
Mailing Address - Zip Code:86514
Mailing Address - Country:US
Mailing Address - Phone:928-656-5474
Mailing Address - Fax:
Practice Address - Street 1:US HWY 160 & NAVAJO RT 35
Practice Address - Street 2:
Practice Address - City:TEEC NOS POS
Practice Address - State:AZ
Practice Address - Zip Code:86514
Practice Address - Country:US
Practice Address - Phone:928-656-5474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22804207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287966Medicaid
114644Medicare ID - Type Unspecified
OR287966Medicaid