Healthcare Provider Details

I. General information

NPI: 1104819689
Provider Name (Legal Business Name): KATHLEEN S JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN S PETTY MD

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1458 CHURCH ST STE B
DECATUR GA
30030-1672
US

IV. Provider business mailing address

1458 CHURCH ST STE B
DECATUR GA
30030-1672
US

V. Phone/Fax

Practice location:
  • Phone: 404-501-6027
  • Fax: 404-377-0550
Mailing address:
  • Phone: 404-508-5012
  • Fax: 404-508-5560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number054906
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: