Provider Demographics
NPI:1265494983
Name:JOHNSON, THEODORE MICHAEL II (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:MICHAEL
Last Name:JOHNSON
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TED
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1365 CLIFTON RD NE
Mailing Address - Street 2:ATLANTA VA MEDICAL CENTER, 508/11B
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1013
Mailing Address - Country:US
Mailing Address - Phone:404-778-3401
Mailing Address - Fax:
Practice Address - Street 1:1365 CLIFTON RD NE
Practice Address - Street 2:ATLANTA VA MEDICAL CENTER, 508/11B
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1013
Practice Address - Country:US
Practice Address - Phone:404-778-3401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049656207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1265494983Medicare UPIN