Provider Demographics
NPI:1114110061
Name:JOHNSON, DOUGLAS T (PA-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 N DECATUR RD SUITE 200
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5825
Mailing Address - Country:US
Mailing Address - Phone:404-296-5005
Mailing Address - Fax:404-296-2070
Practice Address - Street 1:2801 N DECATUR RD STE 200
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5936
Practice Address - Country:US
Practice Address - Phone:404-296-5005
Practice Address - Fax:404-296-2070
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6115363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical