Provider Demographics
NPI:1437323946
Name:JOHNSTON, AMANDA (DO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4160 JOHN R ST STE 400
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2021
Mailing Address - Country:US
Mailing Address - Phone:313-745-8773
Mailing Address - Fax:
Practice Address - Street 1:4160 JOHN R ST STE 400
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2021
Practice Address - Country:US
Practice Address - Phone:313-745-8773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101024264208600000X
MI5151011470208600000X
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery