MEDICARE: BRIAN DOUGLAS JOHNSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	17131	OK

General Provider Information

NPI Number	:	1457748295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN DOUGLAS JOHNSON M.D.

Provider Business Mailing Address
First Line	:	6700 S MACARTHUR BLVD
Second Line	:	CAMI/ AAM-320/ RM 203G
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73169-6907
Country	:	US
Telephone Number	:	405-954-7652
Fax Number	:	405-954-3345

Provider Business Practice Location Address
First Line	:	6700 S MACARTHUR BLVD
Second Line	:	CAMI/ AAM-320/ RM 203G
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73169-6907
Country	:	US
Telephone Number	:	405-954-7652
Fax Number	:	405-954-3345

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2015
Last Update Date	:	04/20/2015

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