1679550933 NPI number — DR. BRENT MITCHELL JOHNSON M.D.

Table of content: BRADLEY D REED HIS (NPI 1154921609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679550933 NPI number — DR. BRENT MITCHELL JOHNSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
BRENT
Provider Middle Name:
MITCHELL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679550933
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2331 FRANKLIN RD SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24014-1111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-725-1226
Provider Business Mailing Address Fax Number:
540-857-5306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2331 FRANKLIN RD SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24014-1111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-725-1226
Provider Business Practice Location Address Fax Number:
540-857-5306
Provider Enumeration Date:
12/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X , with the licence number:  0101043592 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1679550933 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 . This is a "UMWA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810018723 . This is a "MEDICAID OF WEST VIRGINIA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00831109 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 . This is a "SOUTHERN HEALTH/CARENET/CARELINK/COVENTRY" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 540506332005 . This is a "TRICARE/CHAMPUS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 . This is a "HUMANA MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 . This is a "VIRGINIA HEALTH NETWORK" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 . This is a "HEALTHKEEPERS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 . This is a "MEDICAID OF NORTH CAROLINA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 . This is a "VA PREMIER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 . This is a "HEALTHKEEPERS PLUS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 . This is a "GATEWAY" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 . This is a "OPTIMA HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 371194700 . This is a "BLACK LUNG" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679550933 . This is a "INTOTAL" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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