Healthcare Provider Details

I. General information

NPI: 1184667651
Provider Name (Legal Business Name): ANNETTE JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0001
US

IV. Provider business mailing address

1120 15TH ST STE BI1056
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-8623
  • Fax:
Mailing address:
  • Phone: 706-721-8623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number081412
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: