Healthcare Provider Details

I. General information

NPI: 1366498545
Provider Name (Legal Business Name): THOMAS MARK JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 EXECUTIVE CENTER PKWY SUITE 102
FREDERICKSBURG VA
22401-3177
US

IV. Provider business mailing address

7501 GREENWAY CENTER DR SUITE 300
GREENBELT MD
20770-3514
US

V. Phone/Fax

Practice location:
  • Phone: 540-654-5333
  • Fax: 540-654-5334
Mailing address:
  • Phone: 301-441-4577
  • Fax: 301-474-4679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD0057684
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101231064
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD32823
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberMD32823
License Number StateDC
# 5
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberD0057684
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: