Healthcare Provider Details

I. General information

NPI: 1851788376
Provider Name (Legal Business Name): BRANDY JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

8880 SW 45TH BLVD
GAINESVILLE FL
32608-4139
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-4120
  • Fax:
Mailing address:
  • Phone: 561-261-6285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberMT208385
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: