Provider Demographics
NPI:1023007341
Name:JOHNSON, NANCY G (OD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 MEREDYTH DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-0222
Mailing Address - Country:US
Mailing Address - Phone:229-432-7012
Mailing Address - Fax:229-435-0211
Practice Address - Street 1:2709 MEREDYTH DR
Practice Address - Street 2:SUITE 110
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-0222
Practice Address - Country:US
Practice Address - Phone:229-432-7012
Practice Address - Fax:229-435-0211
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001503152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000676882CMedicaid
GA000676882CMedicaid
GA41ZCCTKMedicare ID - Type Unspecified