Provider Demographics
NPI:1568464063
Name:JOHNSON, KIMBALL ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBALL
Middle Name:ANNE
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 1:957 W MARIETTA ST NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-5282
Mailing Address - Country:US
Mailing Address - Phone:404-817-0062
Mailing Address - Fax:404-817-0064
Practice Address - Street 1:957 W MARIETTA ST NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-5282
Practice Address - Country:US
Practice Address - Phone:404-817-0062
Practice Address - Fax:404-817-0064
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA32213207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1689736654OtherGROUP NPI
GA11BDWQTMedicare PIN
GA1689736654OtherGROUP NPI