Provider Demographics
NPI:1578695425
Name:JOHNSON, THOMAS JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOHN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 207163
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7154
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:10 LINCOLN HWY STE 101
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208
Practice Address - Country:US
Practice Address - Phone:618-624-0222
Practice Address - Fax:618-624-4930
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008531152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360070026Medicare NSC
IL210906002Medicare UPIN