Healthcare Provider Details

I. General information

NPI: 1386869410
Provider Name (Legal Business Name): ALTEE S JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 YORKTOWN DR SUITE110
FAYETTEVILLE GA
30214-1578
US

IV. Provider business mailing address

101 YORKTOWN DR SUITE110
FAYETTEVILLE GA
30214-1578
US

V. Phone/Fax

Practice location:
  • Phone: 678-364-5400
  • Fax: 678-364-5399
Mailing address:
  • Phone: 678-364-5400
  • Fax: 678-364-5399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number60387
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: