Provider Demographics
NPI:1588670863
Name:JOHNSTON, KEVIN DOUGLAS (DC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DOUGLAS
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 LEWIS PARK DR
Mailing Address - Street 2:
Mailing Address - City:MT ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549-1202
Mailing Address - Country:US
Mailing Address - Phone:217-864-5954
Mailing Address - Fax:217-864-6362
Practice Address - Street 1:160 LEWIS PARK DR
Practice Address - Street 2:
Practice Address - City:MT ZION
Practice Address - State:IL
Practice Address - Zip Code:62549-1202
Practice Address - Country:US
Practice Address - Phone:217-864-5954
Practice Address - Fax:217-864-6362
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008355111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
350046226OtherRR MEDICARE
350046226OtherRR MEDICARE
552080Medicare ID - Type Unspecified