1831290550 NPI number — DR. THOMAS NELSON JOHNSON OPTOMETRIST

Table of content: TYRONDA THOMAS (NPI 1548514797)

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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