Provider Demographics
NPI:1083641559
Name:JOHNSTON, DOUGLAS FREDERICK (DO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:FREDERICK
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9477
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-9477
Mailing Address - Country:US
Mailing Address - Phone:903-594-2450
Mailing Address - Fax:903-509-0493
Practice Address - Street 1:6210 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4413
Practice Address - Country:US
Practice Address - Phone:903-579-2700
Practice Address - Fax:903-534-9463
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7432207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00050031OtherMEDICARE RR
TX8J0326OtherBLUE CROSS
P00050031OtherMEDICARE RR
P00050031Medicare PIN
TXH48446Medicare UPIN