Provider Demographics
NPI:1477571081
Name:GREENE-JOHNSON, TRACEY (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:
Last Name:GREENE-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 1:327 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4111
Mailing Address - Country:US
Mailing Address - Phone:770-229-1117
Mailing Address - Fax:770-229-5280
Practice Address - Street 1:327 S 9TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4111
Practice Address - Country:US
Practice Address - Phone:770-229-1117
Practice Address - Fax:770-229-5280
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038785174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000629252EMedicaid
GAF94038Medicare UPIN