MEDICARE: DR. BRAD M JOHNSTON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	01056073A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000362157	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1114971223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRAD M JOHNSTON M.D.

Provider Business Mailing Address
First Line	:	3707 NEW VISION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1702
Country	:	US
Telephone Number	:	260-969-1124
Fax Number	:	614-210-1886

Provider Business Practice Location Address
First Line	:	3707 NEW VISION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46895-5602
Country	:	US
Telephone Number	:	260-471-9466
Fax Number	:	260-484-5919

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	04/05/2019

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