Provider Demographics
NPI:1265498687
Name:JOHNSON, CHARLENE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:JOHNSON
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:495 VIRGINIA HIGHLANDS
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-8233
Mailing Address - Country:US
Mailing Address - Phone:770-460-6459
Mailing Address - Fax:
Practice Address - Street 1:2945 STONE HOGAN CONNECTOR RD SW
Practice Address - Street 2:SUITE 201
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2835
Practice Address - Country:US
Practice Address - Phone:404-349-6758
Practice Address - Fax:404-349-6759
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049655208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics