Provider Demographics
NPI:1487676821
Name:JOHNSTON, KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:JOHNSTON
Suffix:
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 1:559 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BURNS
Mailing Address - State:OR
Mailing Address - Zip Code:97720-1441
Mailing Address - Country:US
Mailing Address - Phone:541-573-2074
Mailing Address - Fax:541-573-8893
Practice Address - Street 1:559 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BURNS
Practice Address - State:OR
Practice Address - Zip Code:97720-1441
Practice Address - Country:US
Practice Address - Phone:541-573-2074
Practice Address - Fax:541-573-8893
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23974207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286617Medicaid
ORP00163103OtherRAILROAD MEDICARE
OR838331003OtherBLUE CROSS BLUE SHIELD
ORR119401Medicare ID - Type Unspecified
ORH21450Medicare UPIN