Provider Demographics
NPI:1487682787
Name:JOHNSON, FARRIS T JR (MD)
Entity Type:Individual
Prefix:
First Name:FARRIS
Middle Name:T
Last Name:JOHNSON
Suffix:JR
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 48089
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-8089
Mailing Address - Country:US
Mailing Address - Phone:706-389-3740
Mailing Address - Fax:706-389-3951
Practice Address - Street 1:1500 OGLETHORPE AVE STE 200A
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2165
Practice Address - Country:US
Practice Address - Phone:706-548-5833
Practice Address - Fax:706-548-5608
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA87580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000304224DMedicaid
GAC72427Medicare UPIN
GA08BDNCSMedicare ID - Type Unspecified