Provider Demographics
NPI:1194795401
Name:JOHNSON, ANTHONY P (MD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:P
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 1:4120 N VALDOSTA RD STE A
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-4973
Mailing Address - Country:US
Mailing Address - Phone:229-244-2068
Mailing Address - Fax:229-244-2850
Practice Address - Street 1:4120 N VALDOSTA RD STE A
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-4973
Practice Address - Country:US
Practice Address - Phone:229-244-2068
Practice Address - Fax:229-244-2850
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21922207W00000X
TXF9622207W00000X
GA26877207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00441152AMedicaid
SC2802730003OtherCIGNA PROVIDER NUMBER
NC890159WMedicaid
SC110025Medicaid
SC4232660OtherAETNA PROVIDER NUMBER
SCP00134990OtherMEDICARE RAILROAD
NC890159WMedicaid
SCC61354Medicare UPIN