Provider Demographics
NPI:1871718908
Name:JOHNSON, MARIA ALICIA (DO)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:ALICIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 N BELAIR RD
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3188
Mailing Address - Country:US
Mailing Address - Phone:706-868-3100
Mailing Address - Fax:
Practice Address - Street 1:465 N BELAIR RD
Practice Address - Street 2:SUITE 1B
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3188
Practice Address - Country:US
Practice Address - Phone:706-868-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056634207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08CBCRNMedicare PIN