Provider Demographics
NPI:1164422770
Name:JOHNSTON, BRUCE SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:SAMUEL
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:901 W GREENWOOD ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:ABBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29620-5678
Mailing Address - Country:US
Mailing Address - Phone:864-366-9681
Mailing Address - Fax:864-366-5600
Practice Address - Street 1:901 W GREENWOOD ST
Practice Address - Street 2:SUITE 9
Practice Address - City:ABBEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29620-5678
Practice Address - Country:US
Practice Address - Phone:864-366-9681
Practice Address - Fax:864-366-5600
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC8390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576000003OtherTAX ID
SCRHC210Medicaid
SC080172913OtherRAILROAD MEDICARE
SC080172913OtherRAILROAD MEDICARE
SC080172913OtherRAILROAD MEDICARE
SCAJ8662543OtherDEA
SCD90600Medicare UPIN