Healthcare Provider Details

I. General information

NPI: 1255428025
Provider Name (Legal Business Name): TIMOTHY M JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1979 HURON PKWY
ANN ARBOR MI
48104-4141
US

IV. Provider business mailing address

1979 HURON PKWY
ANN ARBOR MI
48104-4141
US

V. Phone/Fax

Practice location:
  • Phone: 734-344-4567
  • Fax: 734-669-1104
Mailing address:
  • Phone: 734-344-4567
  • Fax: 734-669-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301053410
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number4301053410
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number4301053410
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: