Healthcare Provider Details

I. General information

NPI: 1184784464
Provider Name (Legal Business Name): KATHERINE JOHNSON FIELDS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHERINE JOHNSON

II. Dates (important events)

Enumeration Date: 12/09/2006
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 GENTILLY BLVD
CARTERSVILLE GA
30120-8504
US

IV. Provider business mailing address

221 TECHNOLOGY PKWY NW
ROME GA
30165-1369
US

V. Phone/Fax

Practice location:
  • Phone: 470-490-6860
  • Fax: 678-721-9457
Mailing address:
  • Phone: 762-235-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number049891
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: