Provider Demographics
NPI:1578525267
Name:JOHNSTON, MELISSA KAY (OD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:KAY
Last Name:JOHNSTON
Suffix:
Gender:F
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 1:700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-3077
Practice Address - Country:US
Practice Address - Phone:810-664-1329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004091152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900D41110OtherBLUE CROSS/BLUE SHIELD MI
MI0N64360002Medicare PIN
MI900D41110OtherBLUE CROSS/BLUE SHIELD MI
MIU58971Medicare UPIN