Healthcare Provider Details

I. General information

NPI: 1023547890
Provider Name (Legal Business Name): EVAN MCCARROLL JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 07/01/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 HIGHWAY 54 W STE 500D
FAYETTEVILLE GA
30214-4537
US

IV. Provider business mailing address

3841 GREEN HILLS VILLAGE DR STE 200
NASHVILLE TN
37215-2691
US

V. Phone/Fax

Practice location:
  • Phone: 770-506-5410
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number62961
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number91303
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: