Provider Demographics
NPI:1710977962
Name:JOHNSTONE, RUDOLPH GORDON III (MD)
Entity Type:Individual
Prefix:
First Name:RUDOLPH
Middle Name:GORDON
Last Name:JOHNSTONE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT 453 PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:48 CREEKVIEW CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4800
Practice Address - Country:US
Practice Address - Phone:864-458-7431
Practice Address - Fax:864-458-7463
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13617207K00000X
SCMD13617207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC136178Medicaid
SCD182976910OtherMEDICARE PTAN
SCD18297OtherUNICARE
SC136178Medicaid
SCD182976910OtherMEDICARE PTAN