Provider Demographics
NPI:1821129651
Name:JOHNSON, CHARLES E JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
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 1:3378 VALLEY CIR NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1114
Mailing Address - Country:US
Mailing Address - Phone:404-261-4308
Mailing Address - Fax:
Practice Address - Street 1:3193 HOWELL MILL RD NW
Practice Address - Street 2:SUITE 306
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2119
Practice Address - Country:US
Practice Address - Phone:404-351-7816
Practice Address - Fax:404-355-3322
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA010204OtherMEDICAL LICENSE
581164605OtherFEDERAL TAX ID
GA00073499BMedicaid
GAAJ1130258OtherDEA
GA010204OtherMEDICAL LICENSE