Provider Demographics
NPI:1669580205
Name:JOHNSON, BRADLEY DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 HILLSBORO ST STE D
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27565-3274
Mailing Address - Country:US
Mailing Address - Phone:919-693-3577
Mailing Address - Fax:919-693-3582
Practice Address - Street 1:304 HILLSBORO ST STE D
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-3274
Practice Address - Country:US
Practice Address - Phone:919-693-3577
Practice Address - Fax:919-693-3582
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3075111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC085HJOtherBLUE CROSS/BLUE SHIELD
NCP00160884OtherRAILROAD MEDICARE PROGRAM
NC89085HJMedicaid
NCP00160884OtherRAILROAD MEDICARE PROGRAM
NC085HJOtherBLUE CROSS/BLUE SHIELD