Basic Information
| Provider Information | |||||||||
| NPI: | 1679550933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | MITCHELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2331 FRANKLIN RD SW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407251226 | ||||||||
| FaxNumber: | 5408575306 | ||||||||
| Practice Location | |||||||||
| Address1: | 2331 FRANKLIN RD SW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407251226 | ||||||||
| FaxNumber: | 5408575306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 03/29/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 0101043592 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1679550933 | 01 | VA | AETNA | OTHER | 1679550933 | 01 | VA | UMWA | OTHER | 1679550933 | 05 | VA | MEDICAID | 3810018723 | 01 | VA | MEDICAID OF WEST VIRGINIA | OTHER | P00831109 | 01 | VA | RAILROAD MEDICARE | OTHER | 1679550933 | 01 | VA | SOUTHERN HEALTH/CARENET/CARELINK/COVENTRY | OTHER | 540506332005 | 01 | VA | TRICARE/CHAMPUS | OTHER | 1679550933 | 01 | VA | ANTHEM | OTHER | 1679550933 | 01 | VA | CIGNA | OTHER | 1679550933 | 01 | VA | HUMANA MEDICARE | OTHER | 1679550933 | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER | 1679550933 | 01 | VA | HEALTHKEEPERS | OTHER | 1679550933 | 01 | VA | MEDICAID OF NORTH CAROLINA | OTHER | 1679550933 | 01 | VA | VA PREMIER | OTHER | 1679550933 | 01 | VA | HEALTHKEEPERS PLUS | OTHER | 1679550933 | 01 | VA | GATEWAY | OTHER | 1679550933 | 01 | VA | OPTIMA HEALTH PLAN | OTHER | 1679550933 | 01 | VA | UNITED HEALTHCARE | OTHER | 371194700 | 01 | VA | BLACK LUNG | OTHER | 1679550933 | 01 | VA | INTOTAL | OTHER |