Provider Demographics
NPI:1821209800
Name:JOHNSON, JENNIFER BEDELL (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BEDELL
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 1:11 MOUNT PARAN RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-2209
Mailing Address - Country:US
Mailing Address - Phone:678-312-2470
Mailing Address - Fax:
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-7694
Practice Address - Country:US
Practice Address - Phone:770-995-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA556042085R0202X
MS147262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01194854OtherRAILROAD MEDICARE PTAN
MSP01194854OtherRAILROAD MEDICARE PTAN
MS302I306270Medicare UPIN
MS302I307038Medicare PIN