Provider Demographics
NPI:1275660391
Name:JOHNSON, THOMAS M (DC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9235 MANSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118
Mailing Address - Country:US
Mailing Address - Phone:318-688-2234
Mailing Address - Fax:318-688-2243
Practice Address - Street 1:9235 MANSFIELD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118
Practice Address - Country:US
Practice Address - Phone:318-688-2234
Practice Address - Fax:318-688-2243
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA795111N00000X
LA0795111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAT-85055Medicare UPIN
LA59502Medicare UPIN
LA5-S887Medicare ID - Type Unspecified