MEDICARE: TIMOTHY J. JOHNSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	458	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	NM00P444	OTHER	NM	BC BS OF NM

General Provider Information

NPI Number	:	1205826179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY J. JOHNSON O.D.

Provider Business Mailing Address
First Line	:	8801 HORIZON BLVD NE
Second Line	:	SUITE 360
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87113-1533
Country	:	US
Telephone Number	:	505-828-4923
Fax Number	:	505-213-0103

Provider Business Practice Location Address
First Line	:	1623 CENTRAL AVE
Second Line	:
City	:	LOS ALAMOS
State	:	NM
Zip	:	87544-3018
Country	:	US
Telephone Number	:	505-662-5444
Fax Number	:	505-662-6109

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	04/20/2008

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