Healthcare Provider Details

I. General information

NPI: 1649247370
Provider Name (Legal Business Name): JOEL M JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOEL M JOHNSON MD

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 GREENFIELD DRIVE
TIFTON GA
31794-3795
US

IV. Provider business mailing address

1007 GREENFIELD DR
TIFTON GA
31794-3795
US

V. Phone/Fax

Practice location:
  • Phone: 229-382-9733
  • Fax: 229-387-6161
Mailing address:
  • Phone: 229-382-9733
  • Fax: 229-387-6161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number030799
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: