Provider Demographics
NPI:1376511667
Name:JOHNSON, STACEY W (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:W
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:PO BOX 2258
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799
Mailing Address - Country:US
Mailing Address - Phone:229-226-7544
Mailing Address - Fax:229-226-0314
Practice Address - Street 1:509 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792
Practice Address - Country:US
Practice Address - Phone:229-226-7544
Practice Address - Fax:229-226-0314
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041324208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000706439BMedicaid
GA000706439CMedicaid
GA37BBBFVXMedicare ID - Type Unspecified
GA000706439BMedicaid