Provider Demographics
NPI:1477540771
Name:JOHNSTON, MICHELLE M (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2209 GENESEE STREET
Mailing Address - Street 2:BUSINESS OFFICE ROOM 310
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5930
Mailing Address - Country:US
Mailing Address - Phone:315-801-3282
Mailing Address - Fax:315-801-8391
Practice Address - Street 1:1656 CHAMPLIN AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502
Practice Address - Country:US
Practice Address - Phone:315-624-6241
Practice Address - Fax:315-624-6395
Is Sole Proprietor?:No
Enumeration Date:2005-10-02
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY219360208VP0000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02192381Medicaid
H50543Medicare UPIN
NY02192381Medicaid
NYP00305730Medicare PIN