Provider Demographics
NPI:1184832271
Name:JOHNSTON, SAMUEL LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:LEWIS
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 1:200 HAWKINS DR
Mailing Address - Street 2:E315GH
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-3689
Mailing Address - Fax:
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:E315GH
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-3689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-114065207R00000X, 207RC0000X
ORMD153947207R00000X, 207RC0000X, 207RC0001X
IAMD-4224207RC0000X
IL036114065207RC0001X, 207RC0001X
IAMD-42224207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147126OtherMEDICARE PTAN (INDIVIDUAL)
IL206147OtherMEDICARE PTAN (GROUP)
IL036114065Medicaid
ILP01209465OtherMEDICARE RAILROAD (PROVIDER PTAN)
ILCA4748OtherMEDICARE RAILROAD (GROUP PTAN)