Provider Demographics
NPI:1144245911
Name:JOHNSON, TIMOTHY SHANE (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:SHANE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:T
Other - Middle Name:SHANE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:30 HOPE DR STE 1860
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2036
Practice Address - Country:US
Practice Address - Phone:717-531-8952
Practice Address - Fax:717-531-0098
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4244492082S0105X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016969880001Medicaid