Provider Demographics
NPI:1780987800
Name:JOHNSON, WILLIAM TIMOTHY (DC)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:TIMOTHY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:TIM
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:4820 TWIN CITY HWY
Mailing Address - Street 2:
Mailing Address - City:GROVES
Mailing Address - State:TX
Mailing Address - Zip Code:77619-3131
Mailing Address - Country:US
Mailing Address - Phone:409-962-2221
Mailing Address - Fax:409-962-6362
Practice Address - Street 1:4820 TWIN CITY HWY
Practice Address - Street 2:
Practice Address - City:GROVES
Practice Address - State:TX
Practice Address - Zip Code:77619-3131
Practice Address - Country:US
Practice Address - Phone:409-962-2221
Practice Address - Fax:409-962-6362
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-10
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11639111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB124602Medicare PIN