Provider Demographics
NPI:1972985356
Name:JOHNSON, JOHN WESLEY
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WESLEY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 HURRICANE SHOALD RD NW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046
Mailing Address - Country:US
Mailing Address - Phone:770-995-0823
Mailing Address - Fax:678-252-2249
Practice Address - Street 1:595 HURRICANE SHOALD RD NW
Practice Address - Street 2:SUITE 300
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:770-995-0823
Practice Address - Fax:678-252-2249
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA080871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics