Provider Demographics
NPI:1386724599
Name:BENNETT-JOHNSON, DIANNE JEAN-MARIE (MD)
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:JEAN-MARIE
Last Name:BENNETT-JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6050 PEACHTREE PKWY
Mailing Address - Street 2:SUITE 240-375
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-3336
Mailing Address - Country:US
Mailing Address - Phone:770-279-2427
Mailing Address - Fax:770-279-0639
Practice Address - Street 1:483 INDIAN TRAIL LILBURN RD NW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3717
Practice Address - Country:US
Practice Address - Phone:770-279-2427
Practice Address - Fax:770-279-0639
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037957207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00630638FMedicaid
GA11BDPXLMedicare ID - Type Unspecified
GA00630638FMedicaid