Provider Demographics
NPI:1578650149
Name:JOHNSTON, TIBITHA JANE (LDO)
Entity Type:Individual
Prefix:MISS
First Name:TIBITHA
Middle Name:JANE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2426 SE 157TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-3710
Mailing Address - Country:US
Mailing Address - Phone:503-761-2329
Mailing Address - Fax:
Practice Address - Street 1:3600 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1106
Practice Address - Country:US
Practice Address - Phone:503-249-3429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FC0800X
WAD2024156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician