Healthcare Provider Details

I. General information

NPI: 1831290550
Provider Name (Legal Business Name): THOMAS NELSON JOHNSON OPTOMETRIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 10/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2824 W DIVISION ST
SAINT CLOUD MN
56301-3800
US

IV. Provider business mailing address

2824 W DIVISION ST
SAINT CLOUD MN
56301-3800
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-2020
  • Fax: 320-251-6885
Mailing address:
  • Phone: 320-253-2020
  • Fax: 320-251-6885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberLD22510000
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: