Provider Demographics
NPI:1255323960
Name:JOHNSON, TRACI COLEMAN (MD)
Entity type:Individual
Prefix:DR
First Name:TRACI
Middle Name:COLEMAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TRACI
Other - Middle Name:L
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1700 TREE LANE RD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6782
Mailing Address - Country:US
Mailing Address - Phone:770-972-0330
Mailing Address - Fax:770-985-2683
Practice Address - Street 1:1700 TREE LANE RD
Practice Address - Street 2:SUITE 290
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6782
Practice Address - Country:US
Practice Address - Phone:770-972-0330
Practice Address - Fax:770-985-2683
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047723207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00946646AMedicaid
GA00946646AMedicaid
GAH-62932Medicare UPIN