Provider Demographics
NPI:1477689404
Name:JOHNSTON, JAN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:MARIE
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 1:715 CAMINO CATALINA
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-1631
Mailing Address - Country:US
Mailing Address - Phone:650-704-7651
Mailing Address - Fax:
Practice Address - Street 1:715 CAMINO CATALINA
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-1631
Practice Address - Country:US
Practice Address - Phone:650-704-7651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61754207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100036490Medicaid
KY000000512881OtherANTHEM
KY000000512881OtherANTHEM