Healthcare Provider Details

I. General information

NPI: 1104804863
Provider Name (Legal Business Name): JOHNATHAN PAUL VANSANT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 HOSPITAL RD SUITE B
BLAIRSVILLE GA
30512-3139
US

IV. Provider business mailing address

35 HOSPITAL RD
BLAIRSVILLE GA
30512-3139
US

V. Phone/Fax

Practice location:
  • Phone: 706-439-6862
  • Fax: 706-439-6863
Mailing address:
  • Phone: 706-439-6862
  • Fax: 706-439-6863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD22682
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License NumberMD22682
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number016295
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number40533
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: