Provider Demographics
NPI:1902089725
Name:JOHNSON, BRIAN LACY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LACY
Last Name:JOHNSON
Suffix:
Gender:M
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:PO BOX 602373
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2373
Mailing Address - Country:US
Mailing Address - Phone:828-213-1500
Mailing Address - Fax:828-651-6570
Practice Address - Street 1:509 BILTMORE AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4601
Practice Address - Country:US
Practice Address - Phone:828-213-4411
Practice Address - Fax:866-285-9740
Is Sole Proprietor?:No
Enumeration Date:2007-12-14
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6804162-1205207R00000X
NC201500821207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000068670Medicare PIN