Provider Demographics
NPI:1063447779
Name:JOHNSTON, GREGORY W (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:W
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 1:3705 W MEMORIAL RD
Mailing Address - Street 2:302
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1512
Mailing Address - Country:US
Mailing Address - Phone:405-775-9350
Mailing Address - Fax:405-775-9360
Practice Address - Street 1:3705 W MEMORIAL RD
Practice Address - Street 2:302
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1512
Practice Address - Country:US
Practice Address - Phone:405-775-9350
Practice Address - Fax:405-775-9360
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13773207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100143840AMedicaid
OK612446100OtherMEDICARE RR
OK612446100OtherMEDICARE RR
OK100143840AMedicaid
OK$$$$$$$$$002OtherBC/BS