Provider Demographics
NPI:1184667651
Name:JOHNSON, ANNETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNETTE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 15TH ST STE BI1056
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-721-8623
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0001
Practice Address - Country:US
Practice Address - Phone:706-721-8623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0814122085R0204X
IN010536812085R0202X, 2085R0204X
NC2007-004872085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC810652OtherPARTNERS
NC202008OtherMEDCOST
SCQ0048IMedicaid
NC146GJOtherBCBS
WV3810009237Medicaid
VA1184667651Medicaid
NC5906769Medicaid
IN200294980Medicaid
NC7167180OtherAETNA
IN200294980Medicaid
INF89718Medicare UPIN
VA1184667651Medicaid
NCP00416738Medicare PIN