Provider Demographics
NPI:1598736704
Name:JOHNSTON, LORI S (OD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:S
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 1:3300 W PURDUE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304
Mailing Address - Country:US
Mailing Address - Phone:765-287-8579
Mailing Address - Fax:765-287-8159
Practice Address - Street 1:3300 W PURDUE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304
Practice Address - Country:US
Practice Address - Phone:765-287-8579
Practice Address - Fax:765-287-8159
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003336A152W00000X
IN18003336B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200532270Medicaid
IN000000387321OtherBCBS
IN466220FMedicare PIN
IN000000387321OtherBCBS