Provider Demographics
NPI:1790019008
Name:JOHNSON, TIMOTHY MICAH (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MICAH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FOX TRCE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NY
Mailing Address - Zip Code:14086-3072
Mailing Address - Country:US
Mailing Address - Phone:716-598-6760
Mailing Address - Fax:716-393-3839
Practice Address - Street 1:3290 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1422
Practice Address - Country:US
Practice Address - Phone:716-691-1192
Practice Address - Fax:716-393-3839
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007656152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist