Provider Demographics
NPI:1225734809
Name:JOHNSTON, LOGAN
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LOGAN
Other - Middle Name:MATTHEW
Other - Last Name:PETERSON JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7915 ELTON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-3809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7915 ELTON ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-3809
Practice Address - Country:US
Practice Address - Phone:719-464-5443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program