Provider Demographics
NPI:1942295910
Name:JOHNSON, THOMAS ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALAN
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 1:407 SMITH DR
Mailing Address - Street 2:P.O.BOX 522
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-3655
Mailing Address - Country:US
Mailing Address - Phone:260-925-3116
Mailing Address - Fax:260-925-3269
Practice Address - Street 1:407 SMITH DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-3655
Practice Address - Country:US
Practice Address - Phone:260-925-3116
Practice Address - Fax:260-925-3269
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001657B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100103700AMedicaid
IN100103700AMedicaid
INT69205Medicare UPIN
IN452570LMedicare PIN
IN255970BMedicare PIN
INP00608245Medicare PIN
IN190810Medicare ID - Type Unspecified