MEDICARE: DR. BRAD RUSSELL JOHNSON MD

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	207N00000X	Dermatology Physician	E-4601	AR
2	207ND0101X	MOHS-Micrographic Surgery Physician	E-4601	AR
3	207ND0900X	Dermatopathology Physician	E4601	AR
4	207NI0002X	Clinical & Laboratory Dermatological Immunology Physician	E-4601	AR
5	207NP0225X	Pediatric Dermatology Physician	E-4601	AR
6	207NS0135X	Procedural Dermatology Physician	E-4601	AR

General Provider Information

NPI Number	:	1538165295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRAD RUSSELL JOHNSON MD

Provider Business Mailing Address
First Line	:	9207 HIGHWAY 71 S
Second Line	:	SUITE 9
City	:	FORT SMITH
State	:	AR
Zip	:	72916-9117
Country	:	US
Telephone Number	:	479-649-3376
Fax Number	:	479-646-0133

Provider Business Practice Location Address
First Line	:	9207 HIGHWAY 71 S
Second Line	:	SUITE 9
City	:	FORT SMITH
State	:	AR
Zip	:	72916-9117
Country	:	US
Telephone Number	:	479-649-3376
Fax Number	:	479-646-0133

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

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	09/11/2025

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