Provider Demographics
NPI:1831172485
Name:JOHNSON, THEODORE L (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:L
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 1:194 NORTH STREET
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201
Mailing Address - Country:US
Mailing Address - Phone:802-442-2264
Mailing Address - Fax:802-442-2337
Practice Address - Street 1:194 NORTH STREET
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201
Practice Address - Country:US
Practice Address - Phone:802-442-2264
Practice Address - Fax:802-442-2337
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420006640208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0005309Medicaid
D78593Medicare UPIN
VTVT5309Medicare ID - Type Unspecified