Healthcare Provider Details

I. General information

NPI: 1700998911
Provider Name (Legal Business Name): CRAIG G. JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 WINDY HILL RD SE
MARIETTA GA
30067-8605
US

IV. Provider business mailing address

1234 WILLIAMSWOOD POINTE
DECATUR GA
30033-2800
US

V. Phone/Fax

Practice location:
  • Phone: 770-644-1570
  • Fax:
Mailing address:
  • Phone: 770-888-2524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number29689
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: