Provider Demographics
NPI:1801848486
Name:JOHNSON, THOMAS MARK (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MARK
Last Name:JOHNSON
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 1:1500 ASSOCIATES DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2201
Mailing Address - Country:US
Mailing Address - Phone:563-584-4100
Mailing Address - Fax:563-584-4110
Practice Address - Street 1:1000 LANGWORTHY ST
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-7313
Practice Address - Country:US
Practice Address - Phone:563-584-3425
Practice Address - Fax:563-584-3497
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21505207RC0000X
WI29644207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0160531Medicaid
A01405Medicare UPIN