Provider Demographics
NPI:1568419844
Name:JOHNSON, MILES D (MD)
Entity Type:Individual
Prefix:MR
First Name:MILES
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2600 MARTIN LUTHER KING JR DR SW
Mailing Address - Street 2:STE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-1636
Mailing Address - Country:US
Mailing Address - Phone:678-556-9460
Mailing Address - Fax:678-556-9462
Practice Address - Street 1:150 FIDDLERS RDG
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2684
Practice Address - Country:US
Practice Address - Phone:404-664-4578
Practice Address - Fax:770-991-5012
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2020-04-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA038817207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00622729GMedicaid
GA00622729NMedicaid