Provider Demographics
NPI:1598208944
Name:JOHNSON, TIMOTHY M
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
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 1:2637 PINE TREE DR
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33023-4508
Mailing Address - Country:US
Mailing Address - Phone:845-694-7353
Mailing Address - Fax:
Practice Address - Street 1:2637 PINE TREE DR
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33023
Practice Address - Country:US
Practice Address - Phone:845-694-7353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-02
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
No172A00000XOther Service ProvidersDriver