Provider Demographics
NPI:1801959309
Name:JOHNSON, BRADLEY R
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6812 N. ORACLE RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704
Mailing Address - Country:US
Mailing Address - Phone:520-297-9878
Mailing Address - Fax:520-297-2242
Practice Address - Street 1:6812 N. ORACLE RD
Practice Address - Street 2:SUITE 114
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704
Practice Address - Country:US
Practice Address - Phone:520-297-9878
Practice Address - Fax:520-297-2242
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMD220292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
860791409OtherWPS CHAMPUS TRICARE
AZAZ0372630OtherBLUE CROSS BLUE SHIELD
G01063Medicare UPIN