Provider Demographics
NPI:1407979339
Name:JOHNSON, TIMOTHY DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DAVID
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 1:29321 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHISAGO CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55013-7326
Mailing Address - Country:US
Mailing Address - Phone:651-257-9666
Mailing Address - Fax:651-257-9666
Practice Address - Street 1:29321 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-7326
Practice Address - Country:US
Practice Address - Phone:651-257-9666
Practice Address - Fax:651-257-9666
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2885111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor