MEDICARE: JERRY STEVEN JOHNSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0001X	Radiation Oncology Physician	30487	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053392217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY STEVEN JOHNSON M.D.

Provider Business Mailing Address
First Line	:	116 MIMOSA DR
Second Line	:
City	:	THOMASVILLE
State	:	GA
Zip	:	31792-6605
Country	:	US
Telephone Number	:	229-228-2982
Fax Number	:	229-551-8784

Provider Business Practice Location Address
First Line	:	116 MIMOSA DR
Second Line	:
City	:	THOMASVILLE
State	:	GA
Zip	:	31792-6605
Country	:	US
Telephone Number	:	229-228-2982
Fax Number	:	229-551-8784

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	03/23/2010

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