Provider Demographics
NPI:1790846210
Name:JOHNSON, GINA GONZALEZ (DO)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:GONZALEZ
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 HIGHWAY 54 W
Mailing Address - Street 2:BUILDING 700, SUITE 700
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4557
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1240 HIGHWAY 54 W
Practice Address - Street 2:BUILDING 700, SUITE 700
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4557
Practice Address - Country:US
Practice Address - Phone:404-452-9931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051480207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA358717674AMedicaid
GAH68344Medicare UPIN
GA358717674AMedicaid