Provider Demographics
NPI:1417040544
Name:JOHNSTON, CAROLYN M (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 AVENUE G
Mailing Address - Street 2:
Mailing Address - City:APALACHICOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32320-1576
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1775 ONE HEALING PL
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4600
Practice Address - Country:US
Practice Address - Phone:850-431-5360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056679207V00000X, 207VX0201X
MA277897207VX0201X
FLME144006207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2656198Medicaid
MIE62014Medicare UPIN
MI0P31220004Medicare ID - Type Unspecified