Healthcare Provider Details

I. General information

NPI: 1750731618
Provider Name (Legal Business Name): SPENCER JACOB JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5629 HWY 21 S
RINCON GA
31326
US

IV. Provider business mailing address

5629 HWY 21 S
RINCON GA
31326-9416
US

V. Phone/Fax

Practice location:
  • Phone: 912-295-2133
  • Fax:
Mailing address:
  • Phone: 912-295-2133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number81790
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: