Provider Demographics
NPI:1598772154
Name:JOHNSTON, DEAN LIVINGSTON (MD)
Entity Type:Individual
Prefix:DR
First Name:DEAN
Middle Name:LIVINGSTON
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DEAN
Other - Middle Name:L
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4106 W. LAKE MARY BLVD
Mailing Address - Street 2:#212
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3344
Mailing Address - Country:US
Mailing Address - Phone:407-333-2525
Mailing Address - Fax:407-333-9583
Practice Address - Street 1:4106 W LAKE MARY BLVD
Practice Address - Street 2:#212
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3315
Practice Address - Country:US
Practice Address - Phone:407-333-2525
Practice Address - Fax:407-333-9583
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0037508174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02565OtherBLUE CROSS BLUE SHIELD
FL045599700Medicaid
FL02565OtherBLUE CROSS BLUE SHIELD