Healthcare Provider Details

I. General information

NPI: 1881958601
Provider Name (Legal Business Name): BURLES AVNER JOHNSON III MD/PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

6201 GREENLEIGH AVE FL 2
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2423
  • Fax: 706-721-6918
Mailing address:
  • Phone: 410-933-2704
  • Fax: 410-500-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberD79597
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: