Provider Demographics
NPI:1407830813
Name:JOHNSON, TIMOTHY A (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:A
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 1:15370 LEVAN RD
Mailing Address - Street 2:STE 1
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1903
Mailing Address - Country:US
Mailing Address - Phone:734-464-9055
Mailing Address - Fax:734-464-7522
Practice Address - Street 1:15370 LEVAN RD
Practice Address - Street 2:STE 1
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1903
Practice Address - Country:US
Practice Address - Phone:734-464-9055
Practice Address - Fax:734-464-7522
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056140207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F51649Medicare UPIN
OM78840003Medicare ID - Type Unspecified