Healthcare Provider Details

I. General information

NPI: 1588125793
Provider Name (Legal Business Name): BRET JOHNSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 10/24/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12501 PROSPERITY DRIVE SUITE 100
SILVER SPRING MD
20904-1647
US

IV. Provider business mailing address

12501 PROSPERITY DRIVE SUITE 100
SILVER SPRING MD
20904-1647
US

V. Phone/Fax

Practice location:
  • Phone: 301-681-6730
  • Fax:
Mailing address:
  • Phone: 301-681-6730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberH96714
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberH96714
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: