Basic Information
| Provider Information | |||||||||
| NPI: | 1649241894 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 HUFFMAN MILL ROAD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272158700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365381234 | ||||||||
| FaxNumber: | 3365836811 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 HUFFMAN MILL ROAD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272158700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365381234 | ||||||||
| FaxNumber: | 3365836811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 200100156 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 054753 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00185716 | 01 | GA | RAILROAD MEDICARE | OTHER | P00237086 | 01 | NC | RAILROAD MEDICARE | OTHER | 630636326A | 05 | GA | MEDICAID | 39020509859 | 01 | GA | BCBS | OTHER |