Provider Demographics
NPI:1982991220
Name:JOHNSON, CASEY B (MD)
Entity type:Individual
Prefix:DR
First Name:CASEY
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 MAIN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-2868
Mailing Address - Country:US
Mailing Address - Phone:802-275-4732
Mailing Address - Fax:
Practice Address - Street 1:205 MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-2868
Practice Address - Country:US
Practice Address - Phone:802-275-4732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0015682207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51168738OtherBLUE CROSS-280
AL51170919OtherBLUE CROSS TRUSSVILLE
AL51168737OtherBLUE CROSS BLUE SHIELD