Provider Demographics
NPI:1538165295
Name:JOHNSON, BRAD RUSSELL (MD)
Entity type:Individual
Prefix:DR
First Name:BRAD
Middle Name:RUSSELL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9207 HIGHWAY 71 S
Mailing Address - Street 2:SUITE 9
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-9117
Mailing Address - Country:US
Mailing Address - Phone:479-649-3376
Mailing Address - Fax:479-646-0133
Practice Address - Street 1:9207 HIGHWAY 71 S
Practice Address - Street 2:SUITE 9
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72916-9117
Practice Address - Country:US
Practice Address - Phone:479-649-3376
Practice Address - Fax:479-646-0133
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4601207N00000X, 207ND0101X, 207NI0002X, 207NP0225X, 207NS0135X
ARE4601207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Not Answered207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Not Answered207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Not Answered207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5N536Medicare ID - Type Unspecified