Provider Demographics
NPI:1104932078
Name:JOHNSON, DOUGLAS W (DC)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4796 CANTON RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-3250
Mailing Address - Country:US
Mailing Address - Phone:770-926-9488
Mailing Address - Fax:770-924-7480
Practice Address - Street 1:4796 CANTON RD
Practice Address - Street 2:SUITE 400
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-3250
Practice Address - Country:US
Practice Address - Phone:770-926-9488
Practice Address - Fax:770-924-7480
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA01800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA22311Medicare UPIN