Provider Demographics
NPI:1144203258
Name:JOHNSON, TOBY (MD)
Entity Type:Individual
Prefix:
First Name:TOBY
Middle Name:
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 1:1055 N 500 W
Mailing Address - Street 2:ATT CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1630 E HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3305
Practice Address - Country:US
Practice Address - Phone:559-256-5200
Practice Address - Fax:559-256-5376
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87693207XS0106X
UT12294965-1205207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0196688OtherSTATE OF WASHINGTON
CAP00276609OtherRAILROAD MEDICARE
CA00A876930Medicare ID - Type Unspecified
CAP00276609OtherRAILROAD MEDICARE