Basic Information
| Provider Information | |||||||||
| NPI: | 1578523866 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | EVAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 BROOKLINE AVE | ||||||||
| Address2: | D1234 DANA-FARBER CANCER INSTITUTE | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022155418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176324790 | ||||||||
| FaxNumber: | 6176325786 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 BROOKLINE AVE | ||||||||
| Address2: | DANA-FARBER CANCER INSTITUTE | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022155418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176324790 | ||||||||
| FaxNumber: | 6176325786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 158661 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | J19701 | 01 | MA | BCBS INDEMITY BC ELECT HM | OTHER | 2172993 | 01 | AETNA US HEALTHCARE | OTHER | 45879 | 01 | FALLON COMMUNITY HEALTH P | OTHER | 3185516 | 01 | MASSHEALTH MA MEDICAID | OTHER | 5876473 | 01 | CIGNA | OTHER | 3000439 | 01 | UNITED HEALTH CARE | OTHER | 158661 | 01 | TUFTS | OTHER | 68815DF | 01 | HPHC DFCI ONLY | OTHER |