1831290550 NPI number — DR. THOMAS NELSON JOHNSON OPTOMETRIST

Table of content: DR. THOMAS NELSON JOHNSON OPTOMETRIST (NPI 1831290550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831290550 NPI number — DR. THOMAS NELSON JOHNSON OPTOMETRIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
THOMAS
Provider Middle Name:
NELSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OPTOMETRIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831290550
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2824 W DIVISION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56301-3800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-253-2020
Provider Business Mailing Address Fax Number:
320-251-6885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2824 W DIVISION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56301-3800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-253-2020
Provider Business Practice Location Address Fax Number:
320-251-6885
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X , with the licence number:  LD22510000 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 22-255-2298 . This is a "AETNA (TAX ID)" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 3C169JO . This is a "BCBSM ID#" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22-02504 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22-255-2298 . This is a "SELECT CARE (TAX ID)" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: P00303198 /GP DE6004 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: SPECTARA . This is a "17760" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 20-2552298 . This is a "PREFERRED CARE (TAX ID)" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 539263 . This is a "OPTICHOICE (BCBSM)" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 21-00495 . This is a "MA-MEDICA DISPENSING" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22-255-2298 . This is a "MAYO HEALTH PLAN (TAX ID)" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 48457 . This is a "DAVIS VISION" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 85742JO . This is a "BCBSM CLINIC ID #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 428318000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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