Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0129X | Vascular Surgeon | ME69430 | FL |
NPI | 1023020302 |
---|---|
Provider Name | Brad L Johnson |
First Address | Orlando, FL 32891-0001 |
Second Address | Tampa, FL 33606-3603 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2006 |
Last Update Date | 31/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
28979 | BLUE CROSS BLUE SHIELD (01) | FL |
379635300 | (05) | FL |
G25390 | (02) | FL |