Healthcare Provider Details

I. General information

NPI: 1417528357
Provider Name (Legal Business Name): BRADLEY SCOTT JOHNSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 E MICHIGAN AVE
LANSING MI
48912-1805
US

IV. Provider business mailing address

1140 E MICHIGAN AVE
LANSING MI
48912-1805
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-5655
  • Fax:
Mailing address:
  • Phone: 517-364-5655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberM083810221
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number1417528357
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: