NPIMap

Individual provider Active NPI

Carl David Johnson III, MD

  • Family Medicine Physician
  • Tifton, GA
National Provider Identifier
1023018561
Registry record updated May 8, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
28796 Issued in GA
Practice address
612 Love Ave
Tifton, GA 31794
Phone
(229) 391-3300
Fax
(229) 388-1948
NPI assigned
Jul 27, 2005
Reactivated
Mar 30, 2006
Last updated
May 8, 2015By the provider in NPPES
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on May 8, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 28796 GA Primary

Addresses

Primary practice location

612 Love Ave
Tifton, GA 31794

Mailing address

612 Love Ave
Tifton, GA 31794
Phone (229) 391-3300

Other identifiers 1

IdentifierTypeStateIssuer
000375251EMedicaidGA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20101115000206 GA Practitioner - Family PracticePractitioner - General Practice 4688869704 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family PracticeAlso: General Practice
Education
Medical College of Georgia School of Medicine, 1985
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

101 Yorktown Dr
Fayetteville, GA 30214-1578

101 Yorktown Dr
Suite 100
Fayetteville, GA 30214-7663
Phone (770) 460-4285

612 Love Ave
Tifton, GA 31794-4406
Phone (229) 391-3300

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10
Skin biopsy1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Privia Medical Group of Georgia LLC Family Medicine CurrentSince May 15, 2018 Accepting new patients
Privia Medical Group of Georgia LLC Family Medicine CurrentSince May 15, 2018 Accepting new patients
Homestead Hospice of South Georgia, LLC CurrentSince Jul 25, 2022 Accepting new patients
Privia Medical Group, LLC Family Medicine Past Accepting new patients
Homestead Hospice of South Georgia, LLC Family Medicine PastSince Feb 19, 2023 Accepting new patients

Locations

126 S Access Rd
Chula, GA 31733
Phone (229) 520-3052

101 Yorktown Dr
Ste 100
Fayetteville, GA 30214
Phone (770) 460-4285

110 10th St E
Ste A
Tifton, GA 31794
Phone (229) 520-3052

612 Love Ave
Tifton, GA 31794
Phone (229) 391-3300

Interoperability endpoints

  • Direct secure messaging: carl.johnson.iii.1@8042.direct.athenahealth.com
  • FHIR API: https://api.platform.athenahealth.com/8042/brand/1/csg/1/fhir/r4

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Eternal Faith Hospice and Palliative CareChula, GA, CCN 851504 Hospice Contracted Managing Employee Nov 30, 2021

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1122422400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1431043200000",
    "number": "1023018561",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "612 LOVE AVE",
            "city": "TIFTON",
            "state": "GA",
            "postal_code": "31794",
            "telephone_number": "229-391-3300",
            "fax_number": "229-388-1948"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "612 LOVE AVE",
            "city": "TIFTON",
            "state": "GA",
            "postal_code": "31794",
            "telephone_number": "229-391-3300",
            "fax_number": "229-388-1948"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JOHNSON",
        "first_name": "CARL",
        "middle_name": "DAVID",
        "name_prefix": "Mr.",
        "name_suffix": "III",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2005-07-27",
        "last_updated": "2015-05-08",
        "deactivation_date": "2006-03-21",
        "reactivation_date": "2006-03-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "GA",
            "license": "28796",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000375251E",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Tifton, GA

Sources for this page

Verify at the official NPI Registry.