Provider Demographics
NPI:1023003019
Name:JOHNSTON, LARRY R (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:R
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3442 US HIGHWAY 431
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35950-0203
Mailing Address - Country:US
Mailing Address - Phone:256-593-1234
Mailing Address - Fax:256-593-8553
Practice Address - Street 1:3442 US HIGHWAY 431
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:AL
Practice Address - Zip Code:35950-0203
Practice Address - Country:US
Practice Address - Phone:256-593-1234
Practice Address - Fax:256-593-8553
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH13448Medicare UPIN
AL09353Medicare ID - Type Unspecified