Basic Information
| Provider Information | |||||||||
| NPI: | 1093995334 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SHANEETA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 WESTVIEW DRIVE SW | ||||||||
| Address2: | HARRIS BLDG., 100-A | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047561400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 80 JESSE HILL JR DR SE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303033031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046161000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2007 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 35091547 | OH | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | MD036166 | DC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 068580 | GA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 003132374A | 05 | GA | MEDICAID |