Provider Demographics
NPI:1285781575
Name:JOHNSON, EVELYN DELOIS (MD)
Entity type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:DELOIS
Last Name:JOHNSON
Suffix:
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 1:1600 GLOUCESTER ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-7145
Mailing Address - Country:US
Mailing Address - Phone:912-265-8080
Mailing Address - Fax:
Practice Address - Street 1:1600 GLOUCESTER ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-7145
Practice Address - Country:US
Practice Address - Phone:912-265-8080
Practice Address - Fax:912-265-8513
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039602208000000X
FLME 60541208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00636028BMedicaid