Provider Demographics
NPI:1720060114
Name:JOHNSON, DENISE A (MD)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:A
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 1:1407 SOARING TRL
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-3280
Mailing Address - Country:US
Mailing Address - Phone:678-581-0626
Mailing Address - Fax:
Practice Address - Street 1:895 CANTON RD NE BLDG 100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8935
Practice Address - Country:US
Practice Address - Phone:770-427-8111
Practice Address - Fax:678-784-0254
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056915207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH75451Medicare UPIN
GA18BDGMSMedicare ID - Type Unspecified