Provider Demographics
NPI:1508856105
Name:JOHNSTON, JEFFREY DEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DEAN
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-1484
Mailing Address - Country:US
Mailing Address - Phone:810-664-5991
Mailing Address - Fax:
Practice Address - Street 1:129 W NEPESSING ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-2102
Practice Address - Country:US
Practice Address - Phone:810-664-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4922670001Medicare NSC
MI0N64360003Medicare PIN
MIU59010Medicare UPIN