Provider Demographics
NPI:1255655734
Name:KEENUM, JOHNATHAN P (MD)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:P
Last Name:KEENUM
Suffix:
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 1:1438 CANOOCHEE DR NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5901-B PEACHTREE DUNWOODY RD
Practice Address - Street 2:SUITE B-420
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:256-627-9518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA763922080N0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program