Provider Demographics
NPI:1457343840
Name:JOHNSON, TIMOTHY DARREL (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DARREL
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 1:231 ROCKINGHAM RD
Mailing Address - Street 2:PO BOX 517
Mailing Address - City:BELLOWS FALLS
Mailing Address - State:VT
Mailing Address - Zip Code:05101-3138
Mailing Address - Country:US
Mailing Address - Phone:802-463-4488
Mailing Address - Fax:802-463-2543
Practice Address - Street 1:231 ROCKINGHAM RD
Practice Address - Street 2:
Practice Address - City:BELLOWS FALLS
Practice Address - State:VT
Practice Address - Zip Code:05101-3138
Practice Address - Country:US
Practice Address - Phone:802-463-4488
Practice Address - Fax:802-463-2543
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030-0000215152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006628Medicaid
VT05012OtherBANKER'S LIFE
VT199730OtherCIGNA
VT59403OtherMVP
VTJOHN 0776628OtherBCBS
VT002590OtherVSP
NH99006628Medicaid
VT0174730001OtherDMERC
NH0784400OtherANTHEM
VTT25382Medicare UPIN
VTJOVT 6628Medicare ID - Type Unspecified