Provider Demographics
NPI:1962475582
Name:JOHNSON, KELLEY MARSHALL (MD)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:MARSHALL
Last Name:JOHNSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:DR
Other - First Name:KELLEY
Other - Middle Name:WOODRUFF
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:CHILDREN'S HEALTHCARE OF ATLANTA
Mailing Address - Street 2:2220 NORTH DRUID HILLS ROAD NE-DEPARTMENT OF RADIOLOGY
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329
Mailing Address - Country:US
Mailing Address - Phone:404-785-6532
Mailing Address - Fax:770-730-8535
Practice Address - Street 1:7795 LANDOWNE DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-1063
Practice Address - Country:US
Practice Address - Phone:770-730-8535
Practice Address - Fax:770-730-8535
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0483722085P0229X
GA483722085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100044200OtherKY MEDICAID-NORTON
KY000023033OOtherHUMANA/NORTON
KY50019563OtherPASSPORT/NORTON
KY000000568993OtherANTHEM/NORTON
KY00533044OtherMEDICARE
KY096946OtherSIHO/NORTON
IN200928350Medicaid
GA000852893Medicaid