Provider Demographics
NPI:1770547267
Name:JOHNSON, LORIE N (MD)
Entity type:Individual
Prefix:
First Name:LORIE
Middle Name:N
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 263
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-0263
Mailing Address - Country:US
Mailing Address - Phone:678-429-8146
Mailing Address - Fax:770-288-8642
Practice Address - Street 1:3976 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-4104
Practice Address - Country:US
Practice Address - Phone:678-429-8146
Practice Address - Fax:678-814-4708
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD419112L207V00000X
GA62054207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019726940005Medicaid
PA0019726940001Medicaid
GA653434213BMedicaid
PA1523078OtherBLUE SHIELD
PA0019726940001Medicaid
GAH90257Medicare UPIN