Provider Demographics
NPI:1497989305
Name:JOHNSON, CLARK TIMOTHY
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:TIMOTHY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 S LUZERNE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-3734
Mailing Address - Country:US
Mailing Address - Phone:443-708-8164
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE STREET PHIPPS 279
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0001
Practice Address - Country:US
Practice Address - Phone:410-955-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD76370207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology