Healthcare Provider Details

I. General information

NPI: 1104129204
Provider Name (Legal Business Name): DR. TIMOTHY DAVID JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2010
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DIAMOND HILL RD
BERKELEY HEIGHTS NJ
07922-2104
US

IV. Provider business mailing address

1 DIAMOND HILL RD
BERKELEY HEIGHTS NJ
07922-2104
US

V. Phone/Fax

Practice location:
  • Phone: 908-277-8880
  • Fax: 908-277-8796
Mailing address:
  • Phone: 908-277-8880
  • Fax: 908-277-8796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number256137
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25MA09176700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: