Healthcare Provider Details

I. General information

NPI: 1902868235
Provider Name (Legal Business Name): VANITA JOHNSON DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 DANFORTH ROAD SW
ATLANTA GA
30303
US

IV. Provider business mailing address

PO BOX 142014
FAYETTEVILLE GA
30219
US

V. Phone/Fax

Practice location:
  • Phone: 330-758-4515
  • Fax: 330-758-5121
Mailing address:
  • Phone: 404-964-6325
  • Fax: 404-745-8603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD001019
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: