Healthcare Provider Details

I. General information

NPI: 1467450742
Provider Name (Legal Business Name): ROBERT WILLIAM JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 WALTON WAY WOUND AND HYPERBARIC
AUGUSTA GA
30901-2612
US

IV. Provider business mailing address

PO BOX 31258 ATTN. CONTRACT PHYSICIAN SERVICES
AUGUSTA GA
30903-3058
US

V. Phone/Fax

Practice location:
  • Phone: 706-774-7242
  • Fax: 706-774-7243
Mailing address:
  • Phone: 706-828-2365
  • Fax: 706-774-7243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number015209
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: