Provider Demographics
NPI:1467450742
Name:JOHNSON, ROBERT WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:JOHNSON
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:PO BOX 31258
Mailing Address - Street 2:ATTN. CONTRACT PHYSICIAN SERVICES
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-3058
Mailing Address - Country:US
Mailing Address - Phone:706-828-2365
Mailing Address - Fax:706-774-7243
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:WOUND AND HYPERBARIC
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2612
Practice Address - Country:US
Practice Address - Phone:706-774-7242
Practice Address - Fax:706-774-7243
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0152092086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000176074CMedicaid
SCG15209Medicaid
GAD91020Medicare UPIN