Healthcare Provider Details

I. General information

NPI: 1164495115
Provider Name (Legal Business Name): BRIAN L JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5630 LOWERY RD
NORFOLK VA
23502-2233
US

IV. Provider business mailing address

5630 LOWERY RD
NORFOLK VA
23502-2233
US

V. Phone/Fax

Practice location:
  • Phone: 757-455-5009
  • Fax: 757-362-3577
Mailing address:
  • Phone: 757-455-5009
  • Fax: 757-362-3577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number048364
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0101042937
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number048364
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number048364
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number048364
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number048364
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number049364
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number048364
License Number StateGA
# 9
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number0101042937
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: