Provider Demographics
NPI:1578577441
Name:JOHANSON, TIMOTHY DAVID (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DAVID
Last Name:JOHANSON
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 1:2701 E. ELVIRA RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85756-7124
Mailing Address - Country:US
Mailing Address - Phone:520-626-0923
Mailing Address - Fax:520-626-2808
Practice Address - Street 1:1501 N. CAMPBELL AVE.
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724
Practice Address - Country:US
Practice Address - Phone:952-920-9191
Practice Address - Fax:952-920-0232
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33782208000000X
AZ51152208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1200632OtherMEDICA
MN496002500Medicaid
CP9020830013OtherPREFERRED ONE
MN47B40JOOtherBLUE CROSS BLUE SHIELD
MN496002500Medicaid