Provider Demographics
NPI:1780194472
Name:JOHNSON, GEORGE S
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 FOXHALL RD
Mailing Address - Street 2:
Mailing Address - City:COLONIAL BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:22443-5528
Mailing Address - Country:US
Mailing Address - Phone:804-410-2086
Mailing Address - Fax:804-410-2093
Practice Address - Street 1:543 ALBROUGH BLVD
Practice Address - Street 2:
Practice Address - City:COLONIAL BEACH
Practice Address - State:VA
Practice Address - Zip Code:22443-3601
Practice Address - Country:US
Practice Address - Phone:804-410-2086
Practice Address - Fax:804-410-2093
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-07
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA82-1085546Medicaid