Provider Demographics
NPI:1821256223
Name:JOHNSON, CLYDE D JR (CSA)
Entity Type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:D
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5881 GLENDRIGE DR NE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328
Mailing Address - Country:US
Mailing Address - Phone:404-303-7703
Mailing Address - Fax:
Practice Address - Street 1:5881 GLENDRIGE DR NE
Practice Address - Street 2:SUITE 120
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:404-303-7703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2625-2363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA359555800OtherDEPT OF LABOR