Provider Demographics
NPI:1942214143
Name:JOHNSON, THOMAS J (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4701
Mailing Address - Country:US
Mailing Address - Phone:602-955-1000
Mailing Address - Fax:602-508-4830
Practice Address - Street 1:350 N SWITZER CANYON DR
Practice Address - Street 2:SUITE 130
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4826
Practice Address - Country:US
Practice Address - Phone:928-773-9697
Practice Address - Fax:928-774-4224
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ01128152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ599425Medicaid
AZ599425Medicaid
AZ599425Medicaid