Provider Demographics
NPI:1750731618
Name:JOHNSON, SPENCER JACOB (MD)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:JACOB
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 1:5629 HWY 21 S
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-9416
Mailing Address - Country:US
Mailing Address - Phone:912-295-2133
Mailing Address - Fax:
Practice Address - Street 1:5629 HWY 21 S
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326
Practice Address - Country:US
Practice Address - Phone:912-295-2133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA81790207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine