Provider Demographics
NPI:1023018561
Name:JOHNSON, CARL DAVID III (MD)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:DAVID
Last Name:JOHNSON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 LOVE AVE
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794
Mailing Address - Country:US
Mailing Address - Phone:229-391-3300
Mailing Address - Fax:229-388-1948
Practice Address - Street 1:612 LOVE AVE
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794
Practice Address - Country:US
Practice Address - Phone:229-391-3300
Practice Address - Fax:229-388-1948
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2015-05-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
GA28796207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000375251EMedicaid
GAD40272Medicare UPIN
GA000375251EMedicaid
D40272Medicare UPIN