Healthcare Provider Details

I. General information

NPI: 1578556189
Provider Name (Legal Business Name): BRIAN T JOHNSON MD PL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 CYPRESS BROOK DR SUITE 101
TRINITY FL
34655-4417
US

IV. Provider business mailing address

1805 CYPRESS BROOK DR SUITE 101
TRINITY FL
34655-4417
US

V. Phone/Fax

Practice location:
  • Phone: 727-264-8833
  • Fax: 727-264-8827
Mailing address:
  • Phone: 727-264-8833
  • Fax: 727-264-8827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME0057286
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: