Provider Demographics
NPI:1902868235
Name:JOHNSON, VANITA (DPM)
Entity Type:Individual
Prefix:
First Name:VANITA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 142014
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30219
Mailing Address - Country:US
Mailing Address - Phone:404-964-6325
Mailing Address - Fax:404-745-8603
Practice Address - Street 1:4001 DANFORTH ROAD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303
Practice Address - Country:US
Practice Address - Phone:330-758-4515
Practice Address - Fax:330-758-5121
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001019213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA910342833AMedicaid
GAV05795Medicare UPIN
48SCCSDMedicare PIN
GA910342833AMedicaid