Provider Demographics
NPI:1790717478
Name:JOHNSTON, RICHARD LEAKE (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:LEAKE
Last Name:JOHNSTON
Suffix:
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 1:600 LEIGH DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705
Mailing Address - Country:US
Mailing Address - Phone:662-327-7525
Mailing Address - Fax:662-243-2252
Practice Address - Street 1:600 LEIGH DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705
Practice Address - Country:US
Practice Address - Phone:662-327-7525
Practice Address - Fax:662-243-2252
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18377207R00000X, 207RG0100X
FLTRN-10588207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04604768Medicaid
MS04604768Medicaid
MSI04746Medicare UPIN