Provider Demographics
NPI:1053363390
Name:JOHNSON, THOMAS NORMAN (OD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:NORMAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3257
Mailing Address - Country:US
Mailing Address - Phone:217-214-0299
Mailing Address - Fax:217-641-0028
Practice Address - Street 1:125 N 13TH ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544-1705
Practice Address - Country:US
Practice Address - Phone:641-437-4099
Practice Address - Fax:641-437-0512
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01821152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1053363390Medicaid
IATO1237Medicare UPIN
IA0430210001Medicare NSC
IA21839Medicare ID - Type UnspecifiedMEDICARE