Provider Demographics
NPI:1639136534
Name:JOHNSON, THOMAS MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MARTIN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 VISTA DE LA VINA
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-8348
Mailing Address - Country:US
Mailing Address - Phone:805-975-3577
Mailing Address - Fax:
Practice Address - Street 1:1225 W 190TH ST STE 280
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4305
Practice Address - Country:US
Practice Address - Phone:877-515-8113
Practice Address - Fax:877-538-2102
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0810642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG19477Medicare UPIN