Provider Demographics
NPI:1053317198
Name:JOHNSON, CHARLES TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:TIMOTHY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:C. TIMOTHY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2121 E HARMONY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-221-1000
Mailing Address - Fax:970-297-6860
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:UNIT 100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3401
Practice Address - Country:US
Practice Address - Phone:970-221-1000
Practice Address - Fax:970-297-6860
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38097207RC0000X, 207RC0001X
NE21237207RC0000X
WY6279A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114449900Medicaid
CO87201381Medicaid
COP00970363OtherRAILROAD MEDICARE
NENA1626005Medicare PIN
WY114449900Medicaid
F71129Medicare UPIN
COCOA104970Medicare PIN
NENA1625005Medicare PIN