Basic Information
Provider Information
NPI: 1003010596
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JOHNSON
FirstName: BRADLEY
MiddleName: TYLER
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 133 BENMORE DR STE 100
Address2:  
City: WINTER PARK
State: FL
PostalCode: 327924111
CountryCode: US
TelephoneNumber: 4076444883
FaxNumber: 4076443697
Practice Location
Address1: 133 BENMORE DR STE 100
Address2:  
City: WINTER PARK
State: FL
PostalCode: 327924111
CountryCode: US
TelephoneNumber: 4076444883
FaxNumber: 4076443697
Other Information
ProviderEnumerationDate: 06/11/2007
LastUpdateDate: 12/20/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Y00000XME132490FLY Allopathic & Osteopathic PhysiciansOtolaryngology 

ID Information
IDTypeStateIssuerDescription
02274440005FL MEDICAID


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