Basic Information
| Provider Information | |||||||||
| NPI: | 1326099227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | STANLEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT # 1029 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528678898 | ||||||||
| FaxNumber: | 3527326282 | ||||||||
| Practice Location | |||||||||
| Address1: | DEPT. # 1029 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528678898 | ||||||||
| FaxNumber: | 3527326282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 08/24/2010 | ||||||||
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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 | 207L00000X | ME30185 | CO | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 01301852 | 05 | CO | MEDICAID | D4548 | 01 | CO | RAILROAD MEDICARE | OTHER | A6528 | 01 | CO | ANTHEM/BLUE CROSS | OTHER |