Provider Demographics
NPI:1396789384
Name:JOHNSON, JAY M (MD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:M
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:PO BOX 162972
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30321-2972
Mailing Address - Country:US
Mailing Address - Phone:800-443-3672
Mailing Address - Fax:865-560-7310
Practice Address - Street 1:501 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1415
Practice Address - Country:US
Practice Address - Phone:706-291-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030326207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0003399385FMedicaid
GA930060783OtherRRGA
D40267Medicare UPIN
GA93BDSWB01Medicare PIN
GA0003399385FMedicaid