=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265653232
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA ELIZABETH JOHNSON M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 04/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 445 WINN WAY
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-5843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-294-3742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1213 MARIFRAN DR
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30094-5008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-235-7289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 057376
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------