Provider Demographics
NPI:1992907364
Name:JOHNSON, BRADFORD V (MD)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:V
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 1:6545 FRANCE AVE S
Mailing Address - Street 2:SUITE 150
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2131
Mailing Address - Country:US
Mailing Address - Phone:952-848-5600
Mailing Address - Fax:952-848-5660
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:SUITE 150
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2131
Practice Address - Country:US
Practice Address - Phone:952-848-5600
Practice Address - Fax:952-848-5660
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN500142083P0901X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN402683200Medicaid
MN402683200Medicaid