Provider Demographics
NPI:1780611996
Name:JOHNSON, VEDA C (MD)
Entity type:Individual
Prefix:
First Name:VEDA
Middle Name:C
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 1:2015 UPPERGATE DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-0001
Mailing Address - Country:US
Mailing Address - Phone:404-522-0101
Mailing Address - Fax:404-588-0226
Practice Address - Street 1:35 WHITEFOORD AVE SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30317-1727
Practice Address - Country:US
Practice Address - Phone:404-588-0101
Practice Address - Fax:404-588-0226
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029894208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00509132FMedicaid
D99762Medicare UPIN
GA37BBCMCMedicare ID - Type Unspecified