Provider Demographics
NPI:1376614537
Name:JOHNSON, TIMOTHY DAVID (PTA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5871 CRUMP CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-3824
Mailing Address - Country:US
Mailing Address - Phone:510-468-6712
Mailing Address - Fax:
Practice Address - Street 1:2296 COUNTRY DR
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-5315
Practice Address - Country:US
Practice Address - Phone:510-797-9299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT6097225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant