Provider Demographics
NPI:1801895248
Name:JOHNSON, TIMOTHY C (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MOTT ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-5540
Mailing Address - Country:US
Mailing Address - Phone:646-355-3711
Mailing Address - Fax:
Practice Address - Street 1:128 MOTT ST
Practice Address - Street 2:SUITE 202
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-5540
Practice Address - Country:US
Practice Address - Phone:646-355-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229556207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02671901Medicaid
NY0833U1Medicare PIN
NY02671901Medicaid