Provider Demographics
NPI:1831290550
Name:JOHNSON, THOMAS NELSON (OPTOMETRIST)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:NELSON
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2824 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-3800
Mailing Address - Country:US
Mailing Address - Phone:320-253-2020
Mailing Address - Fax:320-251-6885
Practice Address - Street 1:2824 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3800
Practice Address - Country:US
Practice Address - Phone:320-253-2020
Practice Address - Fax:320-251-6885
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLD22510000152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN22-255-2298OtherAETNA (TAX ID)
MN3C169JOOtherBCBSM ID#
MN22-02504OtherMEDICA
MN22-255-2298OtherSELECT CARE (TAX ID)
MNP00303198 /GP DE6004OtherRAIL ROAD MEDICARE
MNSPECTARAOther17760
MN20-2552298OtherPREFERRED CARE (TAX ID)
MN539263OtherOPTICHOICE (BCBSM)
MN21-00495OtherMA-MEDICA DISPENSING
MN22-255-2298OtherMAYO HEALTH PLAN (TAX ID)
MN48457OtherDAVIS VISION
MN85742JOOtherBCBSM CLINIC ID #
MN428318000Medicaid
MN410002624Medicare ID - Type UnspecifiedMEDICARE B - GROUP C04223
MNU16752Medicare UPIN