Provider Demographics
NPI:1811375249
Name:JOHNSON, MARK ANDREW (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
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 1:254 TRICKUM CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-1711
Mailing Address - Country:US
Mailing Address - Phone:770-876-5649
Mailing Address - Fax:
Practice Address - Street 1:1170 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3615
Practice Address - Country:US
Practice Address - Phone:404-466-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA80598207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine