Provider Demographics
NPI:1457401630
Name:JOHNSON, ANITA (MD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
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:PO BOX 5042
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-0250
Mailing Address - Country:US
Mailing Address - Phone:678-445-0976
Mailing Address - Fax:
Practice Address - Street 1:120 N MEDICAL PKWY BLDG 100
Practice Address - Street 2:SUITE 201
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-7062
Practice Address - Country:US
Practice Address - Phone:678-445-0976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA534642086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology