Basic Information
| Provider Information | |||||||||
| NPI: | 1578577441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHANSON | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 E. ELVIRA RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857567124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206260923 | ||||||||
| FaxNumber: | 5206262808 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 N. CAMPBELL AVE. | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529209191 | ||||||||
| FaxNumber: | 9529200232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 02/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 33782 | MN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 51152 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1200632 | 01 | MEDICA | OTHER | 496002500 | 05 | MN | MEDICAID | CP9020830013 | 01 | PREFERRED ONE | OTHER | 47B40JO | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER |