Provider Demographics
NPI:1548538630
Name:BRIAN T. JOHNSON M.D. PL
Entity type:Organization
Organization Name:BRIAN T. JOHNSON M.D. PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-815-9878
Mailing Address - Street 1:1805 CYPRESS BROOK DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4417
Mailing Address - Country:US
Mailing Address - Phone:727-264-8833
Mailing Address - Fax:727-264-8827
Practice Address - Street 1:1805 CYPRESS BROOK DR
Practice Address - Street 2:SUITE 101
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4417
Practice Address - Country:US
Practice Address - Phone:727-264-8833
Practice Address - Fax:727-264-8827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0057286207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002WHOtherBLUE CROSS/BLUE SHIELD FLORIDA GROUP ID#
FLP01014397OtherRAILROAD MEDICARE
FLDS2914OtherPROV AND GROUP #
FL10230OtherBLUE CROSS/BLUE SHIELD FLORIDA ID #
2372307OtherGHI
FL10230OtherBLUE CROSS/BLUE SHIELD FLORIDA ID #
FLFU094AMedicare PIN