Provider Demographics
NPI:1649247370
Name:JOHNSON, JOEL M (MD)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOEL
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1007 GREENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3795
Mailing Address - Country:US
Mailing Address - Phone:229-382-9733
Mailing Address - Fax:229-387-6161
Practice Address - Street 1:1007 GREENFIELD DRIVE
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3795
Practice Address - Country:US
Practice Address - Phone:229-382-9733
Practice Address - Fax:229-387-6161
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030799208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00374646AMedicaid
$$$$$$$$$AMedicare PIN
GAD05613Medicare UPIN