Provider Demographics
NPI:1376580449
Name:JOHNSTON, EDWIN D JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:D
Last Name:JOHNSTON
Suffix:JR
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 1:4617 OLD DALTON RD NE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-8912
Mailing Address - Country:US
Mailing Address - Phone:706-506-1381
Mailing Address - Fax:
Practice Address - Street 1:616 19TH ST
Practice Address - Street 2:ANESTHESIOLOGY DEPARTMENT
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1528
Practice Address - Country:US
Practice Address - Phone:706-494-4296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029691207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000346937GMedicaid
GA000346937HMedicaid
GAP00217968OtherRAILROAD MEDICARE
GA000346937HMedicaid
GA05BDKPFMedicare ID - Type UnspecifiedMEDICARE