Provider Demographics
NPI:1174595730
Name:JOHNSON, BRAD NATHAN (DO)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:NATHAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W GREENLAWN AVE
Mailing Address - Street 2:#106
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-2898
Mailing Address - Country:US
Mailing Address - Phone:517-482-2118
Mailing Address - Fax:517-482-6280
Practice Address - Street 1:405 W GREENLAWN AVE
Practice Address - Street 2:#106
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2898
Practice Address - Country:US
Practice Address - Phone:517-482-2118
Practice Address - Fax:517-482-6280
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBS015087207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4723010Medicaid
MI4723010Medicaid