Healthcare Provider Details

I. General information

NPI: 1194795401
Provider Name (Legal Business Name): ANTHONY P JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 N VALDOSTA RD STE A
VALDOSTA GA
31602-4973
US

IV. Provider business mailing address

4120 N VALDOSTA RD STE A
VALDOSTA GA
31602-4973
US

V. Phone/Fax

Practice location:
  • Phone: 229-244-2068
  • Fax: 229-244-2850
Mailing address:
  • Phone: 229-244-2068
  • Fax: 229-244-2850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number21922
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberF9622
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number26877
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: