Provider Demographics
NPI:1528010956
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 1:102 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-1129
Mailing Address - Country:US
Mailing Address - Phone:618-667-9766
Mailing Address - Fax:618-667-9770
Practice Address - Street 1:102 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-1129
Practice Address - Country:US
Practice Address - Phone:618-667-9766
Practice Address - Fax:618-667-9770
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210563Medicare ID - Type Unspecified
ILU43842Medicare UPIN