Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | E-4601 | AR |
N | 207ND0101X | MOHS-Micrographic Surgeon | E-4601 | AR |
N | 207ND0900X | Dermatopathologist | E4601 | AR |
N | 207NP0225X | Pediatric Dermatologist | E-4601 | AR |
N | 207NS0135X | Procedural Dermatology | E-4601 | AR |
NPI | 1538165295 |
---|---|
Provider Name | Dr. Brad Russell Johnson |
First Address | Fort Smith, AR 72916-9117 |
Second Address | Fort Smith, AR 72916-9117 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2005 |
Last Update Date | 08/07/2007 |