Provider Demographics
NPI:1558367201
Name:JOHNSTON, LEON MCTYEIRE III (MD)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:MCTYEIRE
Last Name:JOHNSTON
Suffix:III
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 1:217 N BIGELOW RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:CT
Mailing Address - Zip Code:06247-1439
Mailing Address - Country:US
Mailing Address - Phone:860-455-9958
Mailing Address - Fax:
Practice Address - Street 1:217 N BIGELOW RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:CT
Practice Address - Zip Code:06247-1439
Practice Address - Country:US
Practice Address - Phone:860-455-9958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD05710207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7008147Medicaid
MA2077221Medicaid
RI7008147Medicaid
MA2077221Medicaid