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General NPI Number Information
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NPI Number | 1336138783
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Entity Type | Individual
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Provider Name | BRIAN LEE JOHNSON M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/18/2005
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Last Update Date | 12/20/2013
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Provider Practice Location Address
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Address Line | 709 N LINCOLN AVE
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City | JEROME
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State | ID
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Zip | 83338-1851
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Country | US
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Telephone | 208-324-4301
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 587
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City | TWIN FALLS
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State | ID
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Zip | 83303-0587
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Country | US
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Telephone | 208-814-7400
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Fax | 208-814-7491
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | M-9334
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License Number State | ID
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