Provider Demographics
NPI:1669563029
Name:JOHNSON, PETER CHARLES (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:CHARLES
Last Name:JOHNSON
Suffix:
Gender:M
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 1390
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30086-1390
Mailing Address - Country:US
Mailing Address - Phone:706-369-1200
Mailing Address - Fax:706-369-0540
Practice Address - Street 1:965 HAWTHORNE PRK.
Practice Address - Street 2:SUITE 100A
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30086
Practice Address - Country:US
Practice Address - Phone:706-369-1200
Practice Address - Fax:706-369-0540
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034378174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000483755MMedicaid
GA16BBCZCMedicare PIN
GA000483755MMedicaid