Provider Demographics
NPI:1104804863
Name:VANSANT, JOHNATHAN PAUL (MD)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:PAUL
Last Name:VANSANT
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 1:35 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-3139
Mailing Address - Country:US
Mailing Address - Phone:706-439-6862
Mailing Address - Fax:706-439-6863
Practice Address - Street 1:178 HOSPITAL RD
Practice Address - Street 2:SUITE B
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-3139
Practice Address - Country:US
Practice Address - Phone:706-439-6862
Practice Address - Fax:706-439-6863
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD226822085R0202X, 207UN0902X
GA016295207RR0500X
SC40533207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid
GA000135382IMedicaid
GAGRP1721Medicare PIN
GA000135382IMedicaid
GA202I365181Medicare PIN
SCPENDINGMedicare PIN