Provider Demographics
NPI:1013074012
Name:JOHNSON, NATHANIEL III (MD)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:
Last Name:JOHNSON
Suffix:III
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 1:300 REGENCY CREST CT SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-2061
Mailing Address - Country:US
Mailing Address - Phone:404-456-1645
Mailing Address - Fax:
Practice Address - Street 1:3915 CASCADE RD SW
Practice Address - Street 2:STE. T-115
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-8512
Practice Address - Country:US
Practice Address - Phone:404-696-8606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032336174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF21832Medicare UPIN
GA16BDVFTMedicare ID - Type Unspecified