Healthcare Provider Details

I. General information

NPI: 1538165295
Provider Name (Legal Business Name): BRAD RUSSELL JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9207 HIGHWAY 71 S SUITE 9
FORT SMITH AR
72916-9117
US

IV. Provider business mailing address

9207 HIGHWAY 71 S SUITE 9
FORT SMITH AR
72916-9117
US

V. Phone/Fax

Practice location:
  • Phone: 479-649-3376
  • Fax: 479-646-0133
Mailing address:
  • Phone: 479-649-3376
  • Fax: 479-646-0133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberE-4601
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberE-4601
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberE4601
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License NumberE-4601
License Number StateAR
# 5
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberE-4601
License Number StateAR
# 6
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberE-4601
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: