Provider Demographics
NPI:1205826179
Name:JOHNSON, TIMOTHY J (OD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 HORIZON BLVD NE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1533
Mailing Address - Country:US
Mailing Address - Phone:505-828-4923
Mailing Address - Fax:505-213-0103
Practice Address - Street 1:1623 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-3018
Practice Address - Country:US
Practice Address - Phone:505-662-5444
Practice Address - Fax:505-662-6109
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM458152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF5946Medicaid
NMNM00P444OtherBC BS OF NM
NM$$$$$$$$$Medicare PIN
NMF5946Medicaid